Devices and methods for minimally-invasive surgical procedures

ABSTRACT

Devices, instruments and tools for minimally invasive surgical procedures. Port devices and methods for hemostatically sealing and providing a port through a tissue wall that interfaces with a fluid containing chamber, by minimally invasive techniques. Assemblies, instruments and methods for minimally invasive access to and through a tissue wall that interfaces with a fluid containing chamber, and for visualizing same. Instruments, assemblies and methods for minimally invasive surgical procedures, including ablation.

CROSS-REFERENCE

This application claims the benefit of U.S. Provisional Application No.60/997,985, filed Oct. 5, 2007, which application is incorporatedherein, in its entirety, by reference thereto.

FIELD OF THE INVENTION

the present invention relates to the field of minimally invasive surgeryand provides devices, instruments and methods for minimally invasivesurgical procedures.

BACKGROUND OF THE INVENTION

A continuing trend in the performance of cardiac surgical procedures, aswell as other surgical procedures performed on an internal organ ortissue of an organism is toward minimizing the invasiveness of suchprocedures. When entering a fluid containing internal organ to provideaccess for inserting tools therethrough to perform one or more surgicalprocedures, it would be desirable to provide a hemostatic port thatprevents or minimizes introduction of air or other intended fluids orsubstances into the organ, while at the same time preventing substantiallosses of blood or other fluids out of the organ, and while stillproviding an access port through which instruments can gain access to anintended surgical target site.

It would be further desirable to install such a port device in asatraumatic fashion as possible, by minimally invasive methods.

Examples of cardiac surgical procedures that could benefit from such adevice include, but are not limited to: endocardial ablation procedures,valve surgeries, closure of patent foramen ovales, or for any other typeof cardiac procedure requiring access into the heart.

In the cardiac field, cardiac arrhythmias, and particularly atrialfibrillation are conditions that have been treated with some success byvarious procedures using many different types of ablation technologies.Atrial fibrillation continues to be one of the most persistent andcommon of the cardiac arrhythmias, and may further be associated withother cardiovascular conditions such as stroke, congestive heartfailure, cardiac arrest, and/or hypertensive cardiovascular disease,among others. Left untreated, serious consequences may result fromatrial fibrillation, whether or not associated with the other conditionsmentioned, including reduced cardiac output and other hemodynamicconsequences due to a loss of coordination and synchronicity of thebeating of the atria and the ventricles, possible irregular ventricularrhythm, atrioventricular valve regurgitation, and increased risk ofthromboembolism and stroke.

As mentioned, various procedures and technologies have been applied tothe treatment of atrial arrhythmias/fibrillation. Drug treatment isoften the first approach to treatment, where it is attempted to maintainnormal sinus rhythm and/or decrease ventricular rhythm. However, drugtreatment is often not sufficiently effective and further measures mustbe taken to control the arrhythmia.

Electrical cardioversion and sometimes chemical cardioversion have beenused, with less than satisfactory results, particularly with regard torestoring normal cardiac rhythms and the normal hemodynamics associatedwith such.

A surgical procedure known as the MAZE III (which evolved from theoriginal MAZE procedure) procedure involves electrophysiological mappingof the atria to identify macroreentrant circuits, and then breaking upthe identified circuits (thought to be the drivers of the fibrillation)by surgically cutting or burning a maze pattern in the atrium to preventthe reentrant circuits from being able to conduct therethrough. Theprevention of the reentrant circuits allows sinus impulses to activatethe atrial myocardium without interference by reentering conductioncircuits, thereby preventing fibrillation. This procedure has been shownto be effective, but generally requires the use of cardiopulmonarybypass, and is a highly invasive procedure associated with highmorbidity.

Other procedures have been developed to perform transmural ablation ofthe heart wall or adjacent tissue walls. Transmural ablation may begrouped into two main categories of procedures, endocardial andepicardial. Endocardial procedures are performed from inside the wall(typically the myocardium) that is to be ablated, and is generallycarried out by delivering one or more ablation devices into the chambersof the heart by catheter delivery, typically through the arteries and/orveins of the patient. Surgical epicardial procedures are performed fromthe outside wall (typically the myocardium) of the tissue that is to beablated, often using devices that are introduced through the chest andbetween the pericardium and the tissue to be ablated. However, mappingmay still be required to determine where to apply an epicardial device,which may be accomplished using one or more instruments endocardially,or epicardial mapping may be performed. Various types of ablationdevices are provided for both endocardial and epicardial procedures,including radiofrequency (RF), microwave, ultrasound, heated fluids,cryogenics and laser. Epicardial ablation techniques provide thedistinct advantage that they may be performed on the beating heartwithout the use of cardiopulmonary by pass.

When performing procedures to treat atrial fibrillation, an importantaspect of the procedure generally is to isolate the pulmonary veins fromthe surrounding myocardium. The pulmonary veins connect the lungs to theleft atrium of the heart, and join the left atrial wall on the posteriorside of the heart. When performing open chest cardiac surgery, such asfacilitated by a full stemotomy, for example, epicardial ablation may bereadily performed to create the requisite lesions for isolation of thepulmonary veins from the surrounding myocardium. Treatment of atrialablation by open chest procedures, without performing other cardiacsurgeries in tandem, has been limited by the substantial complexity andmorbidity of the procedure. However, for less invasive procedures, thelocation of the pulmonary veins creates significant difficulties, astypically one or more lesions are required to be formed to completelyencircle these veins.

One example of a less invasive surgical procedure for atrialfibrillation has been reported by Saltman, “A Completely EndoscopicApproach to Microwave Ablation for Atrial Fibrillation”, The HeartSurgery Forum, #2003-11333 6 (3), 2003, which is incorporated herein inits entirety, by reference thereto. In carrying out this procedure, thepatient is placed on double lumen endotracheal anesthesia and the rightlung is initially deflated. Three ports (S mm port in fifth intercostalspace, 5 mm port in fourth intercostal space, and a 10 mm port in thesixth intercostal space) are created through the right chest of thepatient, and the pericardium is then dissected to enable two cathetersto be placed, one into the transverse sinus and one into the obliquesinus. Instruments are removed from the right chest, and the right lungis re-inflated. Next, the left lung is deflated, and a mirror reflectionof the port pattern on the right chest is created through the let chest.The pericardium on the left side is dissected to expose the left atrialappendage and the two catheters having been initially inserted from theright side are retrieved and pulled through one of the left side ports.The two catheter ends are then tied and/or sutured together and arereinserted through the same left side port and into the left chest. Theleader of a Flex 10 microwave probe (Guidant Corporation, Santa Clara,Calif.) is sutured to the end of the upper catheter on the right handside of the patient, and the lower catheter is pulled out of a rightside port to pull the Flex 10 into the right chest and lead it aroundthe pulmonary veins. Once in proper position, the Flex 10 isincrementally actuated to form a lesion around the pulmonary veins. Theremaining catheter and Flex 10 are then pulled out of the chest andfollow-up steps are carried out to close the ports in the patient andcomplete the surgery.

Although advances have been made to reduce the morbidity of atrialablation procedures, as noted above, there remains a continuing need fordevices, techniques, systems and procedures to further reduce theinvasiveness of such procedures, thereby reducing morbidity, as well aspotentially reducing the amount of time required for a patient to be insurgery, as well as reducing recovery time. There remains a continuingneed as well for minimizing the invasiveness of other surgicalprocedures performed within the heart.

There remains a continuing need for minimizing the invasiveness of theprocedures for providing access to other internal organs and tissue aswell.

SUMMARY OF THE INVENTION

The present invention provides an assembly usable in performingminimally-invasive ablation procedures is provided that includes: anelongated shaft, a balloon fitted over a distal end of the elongatedshaft, the balloon being configured to assumed a deflated configuration,as well as an inflated configuration wherein the balloon has an outsidediameter greater than an outside diameter of the balloon in the deflatedconfiguration; and a halo comprising wires configured to be positionedproximal of the balloon in a retracted configuration and movable to aposition distal of the balloon in an expanded configuration, wherein,when in the expanded configuration, the halo defines an area larger thana contracted area defined by the halo when in the retractedconfiguration.

In at least one embodiment, the halo is advanceable over the balloonwhen the balloon is in the inflated configuration.

In at least one embodiment, the halo comprises superelastic wires thatexpand a configuration of the halo when moving from the retractedconfiguration to the expanded configuration.

In at least one embodiment, the superelastic wires slide over theballoon and the balloon deforms somewhat as the halo passes from theretracted configuration to deploy over the balloon to the expandedconfiguration.

In at least one embodiment, a plurality of push rods are connected tothe halo, the push rods being axially slidable relative to the shaft tomove the halo from the retracted configuration position and thedeployed, expanded configuration position and vice versa.

In at least one embodiment, an actuator is connected to proximal ends ofthe push rods, the actuator being slidable over the shaft.

In at least one embodiment the actuator comprises an extension extendingproximally to a proximal end portion of the shaft.

In at least one embodiment, the halo is electrically connectable to asource of ablation energy proximal of the assembly.

In at least one embodiment, the halo is connectable to a source ofablation energy proximal of the assembly.

In at least one embodiment, a conduit connecting with the balloonextends proximally of a proximal end of the shaft, the conduit beingconnectable in fluid communication with a source of pressurized fluid.

In at least one embodiment, the shaft comprises a cannula, the cannulabeing configured and dimensioned to receive an endoscope shaft therein,with a distal tip of the endoscope being positionable within theballoon.

In at least one embodiment, the shaft comprises a shaft of an endoscope.

In at least one embodiment, the halo is formed of two wires and forms asubstantially oval shape when in the expanded configuration.

In at least one embodiment, the halo forms an encircling shape when inthe expanded configuration.

In at least one embodiment, the halo is formed of four wires and forms asubstantially quadrilateral shape when in the expanded configuration.

An instrument usable in performing minimally-invasive ablationprocedures is provided that includes: an elongated shaft; a balloonfitted over a distal end of the elongated shaft, the balloon beingconfigured to assume a deflated configuration, as well as an inflatedconfiguration wherein the balloon has an outside diameter greater thanan outside diameter of the balloon in the deflated configuration; and ahalo comprising wires configured to be positioned proximal of theballoon in a retracted configuration and movable to a position distal ofthe balloon in an expanded configuration, wherein, when in the expandedconfiguration, the halo defines an area larger than a contracted areadefined by the halo when in the retracted configuration; and anendoscope having a distal tip thereof positioned adjacent to an openingof the balloon or within the balloon.

In at least one embodiment, the shaft comprises a shaft of theendoscope.

In at least one embodiment, the shaft comprises a cannula and wherein ashaft of the endoscope is received in the cannula.

In at least one embodiment, the halo is advanceable over the balloonwhen the balloon is in the inflated configuration.

In at least one embodiment, the halo comprises superelastic wires thatexpand a configuration of the halo when moving from the retractedconfiguration to the expanded configuration.

In at least one embodiment, the superelastic wires slide over theballoon and the balloon deforms somewhat as the halo passes from theretracted configuration to deploy over the balloon to the expandedconfiguration.

In at least one embodiment, a plurality of push rods are connected tothe halo, the push rods being axially slidable relative to the shaft tomove the halo from the retracted configuration position and thedeployed, expanded configuration position and vice versa.

In at least one embodiment, an actuator is connected to proximal ends ofthe push rods, the actuator being slidable over the shaft.

In at least one embodiment, the actuator comprises an extensionextending proximally to a proximal end portion of the endoscope.

In at least one embodiment, the halo is electrically connectable to asource of ablation energy proximal of the instrument.

In at least one embodiment, the halo is connectable to a source ofablation energy proximal of the instrument.

In at least one embodiment, a conduit connecting with the balloonextends proximally of a proximal end portion of the shaft, the conduitbeing connectable in fluid communication with a source of pressurizedfluid.

In at least one embodiment, the halo is formed of two wires and forms asubstantially oval shape when in the expanded configuration.

In at least one embodiment, the halo forms an encircling shape when inthe expanded configuration.

In at least one embodiment, the halo is formed of four wires and forms asubstantially quadrilateral shape when in the expanded configuration.

These and other features of the invention will become apparent to thosepersons skilled in the art upon reading the details of the devices,assemblies, instruments and methods as more fully described below.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A-1B illustrate longitudinal sectional views of a hemostatic portdevice that can be installed by minimally invasive techniques.

FIG. 1C shows a view of the device of FIGS. 1A-1B having been installedthrough an opening in tissue, and expandable members of the devicehaving been expanded to capture the tissue therebetween and form ahemostatic seal therewith.

FIGS. 2A and 28 illustrate steps in one example of installation of aport device in the left atrial appendage of the heart of a patient.

FIGS. 2C and 2D illustrate an arrangement configured for quick and easyremovability of a dilator from to a port device.

FIGS. 3A-3C illustrate another version of a port device and proceduralsteps included in its installation.

FIGS. 4A-4E illustrate another version of a port device and proceduralsteps included in its installation.

FIGS. 5A-5D illustrate another version of a port device and proceduralsteps included in its installation.

FIGS. 6A-6B illustrate another version of a port device.

FIG. 7A illustrates a closure device that may be used to close anopening through a tissue wall upon removal of a port device therefrom.

FIGS. 7B-7D show steps that may be performed using the device of FIG. 7Ato close an opening.

FIGS. 8A-8B illustrate a port device that can be used to provide anopening into an atrial appendage for insertion of tools and/or devicestherethrough to carry out a procedure inside a chamber of the heart.

FIGS. 8C-8D illustrate mechanical linkage that may be provided so thatrotation of only one cylinder of the device of FIGS. 8A-8B causes linkedrotation of both rollers.

FIG. 9 illustrates a partial sectional view of another port device.

FIG. 10 illustrates a port device comprising a cannula having a closabledistal end portion.

FIG. 11 illustrates another version of a port device.

FIG. 12 illustrates another version of a port device.

FIG. 13 illustrates another version of a port device.

FIG. 14A illustrates a distal end portion of an assembly that can beinserted through a port device to visualize structures in the internalchamber accessed through the port device as well as to perform ablationprocedures.

FIG. 14B shows the distal end portion of the assembly of FIG. 14A withballoon inflated/expanded and halo deployed.

FIG. 14C is a distal end view of the balloon and halo of FIG. 14B.

FIG. 14D shows the assembly of FIG. 14A with balloon in a non-inflated,configuration, with halo deployed in the extended and expandedconfiguration, and with an endoscope fully inserted.

FIGS. 15A-15B illustrate a halo assembly wherein the halo is formed fromfour superelastic wires

FIG. 15C shows a portion of an assembly having a four-wire halo.

FIG. 15D illustrates an assembly having a four wire halo, with the haloshown in the deployed position and expanded configuration, and with theballoon in a deflated, non-expanded configuration.

FIG. 15E shows the assembly of FIG. 15D with the halo in a retractedposition and compressed configuration, and wherein the balloon has beeninflated/expanded.

FIG. 15F shows the halo beginning to be deployed over theexpanded/inflated balloon.

FIG. 15G shows the halo fully deployed over the inflated balloon so thatit resides against the distal surface of the inflated balloon.

FIG. 15H shows the substantially expanded configuration of the halo atthe distal surface of balloon.

FIG. 16 illustrates a distal end portion of an assembly configured toform a linear lesion while directly viewing the tissue in which thelesion is being formed.

FIG. 17 illustrates an assembly that combines the linear ablationcapabilities of the assembly of FIG. 16 with the encircling lesionforming capabilities of a halo.

FIG. 18 illustrates steps that may be carried out during a minimallyinvasive procedure using one or more of the devices and/or instrumentsdescribed herein.

FIG. 19 illustrates an endoscopic trocar assembly configured to receivean endoscope therein for use as an instrument to visualize piercingthrough a tissue wall and gaining access to an interior chamber locatedinside the tissue wall.

FIGS. 20A-20B illustrate steps of using the assembly and endoscopedescribed with regard to FIG. 19.

FIGS. 20C-20F illustrate using the trocar of FIG. 19 with the assemblyof FIG. 21A to close the tract formed by the procedure of FIGS. 20A-20B.

FIG. 20G illustrates use of a sliding suture loop inside a knot pusherto secure a seal against the inner wall of the left ventricle.

FIGS. 21A-21C illustrate an assembly useable in a minimally invasiveprocedure to seal a tract or opening through the wall of an organ,vessel or other tissue.

FIG. 22A illustrates a conical or wedge-shaped seal comprising collagen,connected to a suture which passes through an inner tube.

FIG. 22B illustrates a spherical or ball-shaped seal comprisingcollagen, connected to a suture which passes through an inner tube.

FIG. 23A illustrates a conical or wedge-shaped seal having been wedgedinto the opening in the myocardial wall to seal the opening.

FIG. 23B illustrates a spherical or ball-shaped seal inserted into thetract in the myocardial wall to seal the same.

DETAILED DESCRIPTION OF THE INVENTION

Before the present devices and methods are described, it is to beunderstood that this invention is not limited to particular embodimentsdescribed, as such may, of course, vary. It is also to be understoodthat the terminology used herein is for the purpose of describingparticular embodiments only, and is not intended to be limiting, sincethe scope of the present invention will be limited only by the appendedclaims.

Where a range of values is provided, it is understood that eachintervening value, to the tenth of the unit of the lower limit unlessthe context clearly dictates otherwise, between the upper and lowerlimits of that range is also specifically disclosed. Each smaller rangebetween any stated value or intervening value in a stated range and anyother stated or intervening value in that stated range is encompassedwithin the invention. The upper and lower limits of these smaller rangesmay independently be included or excluded in the range, and each rangewhere either, neither or both limits are included in the smaller rangesis also encompassed within the invention, subject to any specificallyexcluded limit in the stated range. Where the stated range includes oneor both of the limits, ranges excluding either or both of those includedlimits are also included in the invention.

Unless defined otherwise, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs. Although any methods andmaterials similar or equivalent to those described herein can be used inthe practice or testing of the present invention, the preferred methodsand materials are now described. All publications mentioned herein areincorporated herein by reference to disclose and describe the methodsand/or materials in connection with which the publications are cited.

It must be noted that as used herein and in the appended claims, thesingular forms “a”, “an”, and “the” include plural referents unless thecontext clearly dictates otherwise. Thus, for example, reference to “alumen” includes a plurality of such lumens and reference to “the target”includes reference to one or more targets and equivalents thereof knownto those skilled in the art, and so forth.

The publications discussed herein are provided solely for theirdisclosure prior to the filing date of the present application. Nothingherein is to be construed as an admission that the present invention isnot entitled to antedate such publication by virtue of prior invention.Further, the dates of publication provided may be different from theactual publication dates which may need to be independently confirmed.

Definitions

The term “open-chest procedure” refers to a surgical procedure whereinaccess for performing the procedure is provided by a full stemotomy orthoracotomy, a stemotomy wherein the sternum is incised and the cutsternum is separated using a sternal retractor, or a thoracotomy whereinan incision is performed between a patient's ribs and the incisionbetween the ribs is separated using a retractor to open the chest cavityfor access thereto.

The term “closed-chest procedure” or “minimally invasive procedure”refers to a surgical procedure wherein access for performing theprocedure is provided by one or more openings which are much smallerthan the opening provided by an open-chest procedure, and wherein atraditional stemotomy is not performed. Closed-chest or minimallyinvasive procedures may include those where access is provided by any ofa number of different approaches, including mini-stemotomy, thoracotomyor mini-thoracotomy, or less invasively through a port provided withinthe chest cavity of the patient, e.g., between the ribs or in asubxyphoid area, with or without the visual assistance of athoracoscope. It is further noted that minimally invasive procedures arenot limited to closed-chest procedures but may be carried out in otherreduced-access, surgical sites, including, but not limited to, theabdominal cavity, for example.

The term “reduced-access surgical site” refers to a surgical site oroperating space that has not been opened fully to the environment foraccess by a surgeon. Thus, for example, closed-chest procedures arecarried out in reduced-access surgical sites. Other procedures,including procedures outside of the chest cavity, such as in theabdominal cavity or other locations of the body, may be carried out asreduced access procedures in reduced-access surgical sites. For example,the surgical site may be accessed through one or more ports, cannulae,or other small opening(s), sometimes referred to as “minimally invasivesurgery”. What is often referred to as endoscopic surgery is surgerycarried out in a reduced-access surgical site.

Devices and Methods

FIGS. 1A-1B illustrate longitudinal sectional views of a hemostatic portdevice 10 that can be installed by minimally invasive techniquesdescribed herein. Device 10 includes a flexible, malleable orsubstantially rigid cannula 12 having two expandable members 14 a and 14b mounted circumferentially around a distal end portion of cannula 12,wherein one of the expandable members 14 a is mounted distally of theother 14 b. Examples of materials from which cannula 12 may be madeinclude but are not limited to, polycarbonate, stainless steel,polyurethane, silicone rubber, polyvinyl chloride, polyethylene, nylon,C-FLEX® (thermoplastic elastomer), etc. Expandable members 14 a,14 b aretypically mounted with a small space or gap 16 therebetween (e.g., abouttwo to about 10 mm), where a tissue wall of an organ, conduit or othertissue is to be captured between the expandable members 14 a,14 b. Inthe example shown in FIGS. 1A-1B, dedicated lumens 16 a, 16 b areprovided to connect expandable members 14 a, 14 b in fluid communicationwith a source of pressurized fluid located proximal of the proximal endof device 10 for delivering pressurized fluid to inflate the expandablemembers 14 a,14 b as shown in FIG. 1B. Alternatively, although lesspreferred, both expandable members 14 a, 14 b could be provided in fluidcommunication with a pressurized fluid source via a single lumen.

When inflated, expandable members 14 a, 14 b expand to expandedconfigurations which narrow the gap 16 therebetween (or completelyeliminate the gap, as illustrated in FIG. 1B) when no tissue is providedtherebetween, as the outside diameters of the expandable membersincrease significantly. These diameters will vary depending upon thespecific application for which device 10 is to be used, and on theoutside diameter of the cannula 12. In one specific example, the insidediameter of conduit 12 is about 10 mm, the outside diameter is greaterthan 10 mm and less than about 12 mm; and in the delated, compact, ornon-expanded configuration of expandable members 14 a and 14 b (shown inFIG. 1A), the expandable members 14 a, 14 b have outside diameters ofabout 12 mm to about 14 mm, while in an expanded configuration, theoutside diameters of the expandable members 14 a. 14 b can range fromabout 100 mm to about 500 mm. FIG. 1C shows a view of device 10 havingbeen installed through an opening in tissue 1 and expandable members 14a, 14 b having been expanded to capture the tissue 1 therebetween andform a hemostatic seal therewith.

The proximal end portion of port device 1I, i.e., the proximal portionof cannula 12 not having the expandable members 14 a, 14 b thereon mayexpand only a minimal distance proximally of expandable member 14 b,e.g., about 0.5 to about 2 inches. Alternatively, depending upon the useof device 10, this proximal portion may extend a much greater distance.For example, in minimally invasive procedures where port device 1I isinstalled in an internal organ, the proximal end of device 10 willextend a sufficient length to be able to extend out of the patient whendevice 10 is installed in the organ as intended. In one example, wheredevice 10 is installed in the left atrial appendage of the heart of apatient the proximal end of conduit 10 extends from about 6 to about 10inches proximally of the proximal surface of expandable member 14 b.

In this embodiment, as well as any of the other embodiments describedherein that include cannula 12, a hemostatic valve 15 may be providedwithin the proximal annular opening of cannula 12, to hemostaticallyseal the port when no instrument or device is being insertedtherethrough. Additionally, valve 15 may at least partially seal againstan instrument, tool or device as it is being inserted through cannula 12so as to prevent or minimize loss of blood or other fluids throughcannula 12 during such an insertion.

FIGS. 2A and 2B illustrate steps in one example of installation of portdevice 10 in the left atrial appendage 4 of the heart 2 of a patient.Atrial appendage management, and particularly left atrial appendage(LAA) management, is a critical part of the surgical treatment of atrialfibrillation. When using a minimally invasive approach (e.g., wheresurgical access is provided by thoracoscopy, mini-thoracotomy or thelike), there is a high risk of complications such as bleeding when usingcontemporary atrial appendage management. Further, exposure and accessto the base of the atrial appendage to be treated is limited by thereduced-access surgical site. Since the atrial appendage is typicallyclosed off, ligated, clamped, sutured, removed (e.g., transected), orotherwise isolated from circulation in the heart, one aspect of thepresent invention provides devices and methods for establishing accessto the left atrium of the heart by installing port device 10 in theatrial appendage 4. Advantageously, this reduces the number of openingsthat need to be made in the heart, such as to perform ablation, forexample, since the atrial appendage would be cut or ligated anyway, andit is also used here as the access location/opening into the heart forinsertion of minimally invasive tools to perform a cardiac procedure.Such procedures, as well as ligating or occluding the atrial appendage 4can be performed while the heart continues to beat, and all by aminimally invasive approach. Such procedures may be performed solelyfrom an opening in the left chest, or may be performed with additionalopenings in the chest, but still with only access through the left atriaappendage. It is again noted here that the present devices an methodsare not limited to installation in the left atrial appendage or toeither atrial appendage, but can be installed anywhere on the heart toprovide access to one or more internal chambers thereof. Still further,the devices and methods described herein can be used to gain access toother internal organs, vessels, or tissues having an internal fluidcontaining chamber, by minimally invasive procedures, while preventingair or other unwanted substances from entering such chamber and whileproviding a hemostatic seal with the entry opening in the tissue tosubstantially prevent blood or other fluids from exiting such chambervia the opening.

FIG. 2A illustrates a removable dilator 18, extending distally of thedistal end of device 10, being used to pierce through the tissue wall ofthe left atrial appendage to form an opening therein. Optionally,graspers, or some other endoscopic clamping tool 20 may be used toengage the atrial appendage 4 to provide a traction force against theforce of the dilator against the atrial appendage as it pierces through.Dilator 18 can be conically shaped, as shown, so as to dilate theopening formed by tip 18 as the dilator is advanced further distallyinto the left atrial appendage. As the dilator 18 is inserted all theway through the opening, the distal end portion of device 10 follows andexpandable member 14 a is positioned inside the tissue wall of theatrial appendage while expandable member 14 b is positioned just outsidethe tissue wall of the atrial appendage 4. Expandable member 14 a isnext inflated so as to expand it to have an outside diameter thatprevents it form being pulled back through the opening in the atrialappendage 4. At this time, the dilator 18 can be retracted and removedfrom the device 10. Alternatively, expandable member 14 b may first beexpanded, prior to withdrawal of the dilator 18. Dilator 18 may besimply held in the relative position shown in FIG. 2A as it is insertedthrough the atrial appendage, with device 10 being held stationaryrelative to dilator 18 and thus advanced along with it. Alternatively,dilator 18 may be removably and temporarily attached to device 10. Oneconfiguration for such removable attachment is illustrated in FIGS. 2Cand 2D, wherein the proximal end portion of dilator 18 is provided withan enlarged diameter proximal end portion 18 a that acts as a stopagainst the proximal end 10 a of device 10. In this way, dilator 18 canbe slid into device 10 and used therein with the distal end portionextending from the distal end of device 10 as shown in FIG. 2A. Removalof dilator 18 can be performed by simply sliding dilator 18 back out ofdevice 10. Of course, other alternative mechanical connectingconfiguration can be substituted for this arrangement, as would bereadily apparent to one of ordinary skill in the mechanical arts.

After inflation of expandable member 14 a, the second expandable member14 b can be inflated to expand (either before or after removal ofdilator 18, as noted) to, together with expanded expandable member 14 b,form a hemostatic seal of the opening through the atrial appendage. Thisseal is very atraumatic as the expandable members 14 a, 14 b do notexpand radially within and against the opening, but apply axialcompression to the tissues surrounding the opening (and to the interfacewith the opening) to seal it. This is particularly important when theaccess opening is made in the atrial appendage 4, as the tissue of theatrial appendage 4 tends to be very friable so that if a seal isattempted by expanding something radially within the opening, the tissuetends to tear or otherwise disintegrate or fail. Axial compression ofthe tissues does not pose such risks, but actually helps maintain theintegrity of these tissues and thus forms the seal in a very atraumaticway. This also provides a very stable connection, as once the moredistal expandable member 14 a is expanded, as shown in FIG. 2B, device10 is not easily removed and very unlikely to be accidentally displacedor removed. The compressive forces provided by expandable member 14 bfurther add to this stability. Optionally, expandable member 14 b neednot always even be expanded, as expandable member 14 a may expandsufficiently to compress against the inner wall surfaces of the atrialappendage to maintain device 10 in a stable position and to form ahemostatic seal of the opening through which device 10 passes. However,the additional stability and sealing provided by expandable member 14 bmakes expansion of the expandable member 14 b a typical step that isperformed during an installation of device 10. In one specificembodiment, with insertion of a device 10 having a 10 mm cannula 12,expandable member 14 a, 14 b are provided as elastomeric balloons andeach inflated with about 7 to about 10 cc of saline.

Expandable members are typically formed as inflatable balloons, e.g.,comprising a compliant material such as latex, silicone, polyurethane,or the like, or a semi-compliant or non-compliant material such asnylon, polyethylene, polyester, polyamide, polyethylene terepthalate(PET) and urethane, for example, with compliant materials beingpreferred, since they can be compressed to a smaller cross-sectionalarea for delivery into the patient and through the opening in thetissue. Alternative forms of expandable members 14 a, 14 b can beprovided, including, but not limited to members comprising closed-cellfoam that is compressible and self-expands when a compression force isremoved, self expanding stents with attached graft material, etc. Whenself-expanding, a sheath, additional cannula or other structure forcompressing the expandable members 14 a. 14 b can be used for deliveryto the expandable members to the locations on opposite sides of thetissue wall in which the opening to be sealed is formed, and thenremoval of the sheath, cannula or other compression applying member isremoved to allow the expandable members to self-expand, eithersequentially (14 a first, then 14 b) or together.

FIGS. 3A-3C illustrate another version of a port device 10 andprocedural steps included in its installation. Although shown beinginstalled in a left atrial appendage, device 10 can be installedanywhere on the heart 2 for access into the heart 2. Furtheralternatively, device 10 can be installed in any of the other internalorgans, vessels or other tissues described previously. In FIG. 3A,expandable members 14 a, 14 b and a sheath 22 are wrapped around anintroducer needle 24 having a sharp distal tip 24 t. The wrapped,compacted configuration of expandable members 14 a, 14 b and sheath 22as shown in FIG. 3A can be maintained using a tie, an additional sheathwrapped around the compacted configuration, or a thin cannula that isslidably removable from the configuration, for example. Alternatively,the sheath 22 may include a superelastic material, such asnickel-titanium alloy or other superelastic material. For example, astent or framework capable of collapsing and then resiliently returningto an expanded configuration can be provided, and can be covered by anon-porous material, such as silicone, or one of the other polymersnoted herein for making sheath 22. Sheath 22 is a thin, flexible,tubular component, such as a piercing needle (can be any size, buttypically 16 or 18 gauge) on which expandable members 14 a, 14 b aremounted, and, in the case where expandable members 14 a, 14 b areinflatable, also contains one or two lumens for inflating the expandablemembers 14 a, 14 b, wherein the one or two lumens are configured in thesame manner as in the cannula 12 described with regard to FIG. 1A above.Sheath 22 and expandable members 14 a, 14 b (in a non-expanded, compactconfiguration) are twisted around introducer needle 24 to form a verycompact cross-sectional area to minimize the size of the openingsrequired for insertion into the patient and for insertion into theorgan, vessel or other tissue, in this case, the left atrial appendage4.

The assembly in the compact configuration is then driven against thetarget area (e.g., left atrial appendage) whereby driving the sharpdistal tip 24 t of introducer needle against the tissue pierces thetissue, thereby forming an opening that is no larger than it has to beto allow passage of the assembly therethrough. Alternatively, anincision can be made with an additional cutting instrument and then theintroducer needle and compact configuration can be inserted through theincision. However, by making the opening with the introducer needle tip24 t and expanding it by driving the needle 24 and compact components 14a and 22 therethrough, this ensures that the opening is kept to aminimum size required. Further alternatively, a tool 20 may be used toprovide a traction force on the atrial appendage or other tissue to beincised or pierced, to facilitate this step.

Once the needle tip 24 t and expandable member 14 a have been passedthough the opening and positioned interiorly of the opening and thetissue wall of atrium 4, the compression member 25, in this case anadditional outer sheath 25 is removed and expandable member 14 a isexpanded (in this case, inflated) thereby securing it within the atrialappendage 4. Expandable member 14 b can be expanded either before orafter withdrawal of needle 24 from the site, thereby forming an axiallycompressive hemostatic seal at and/or around the site of the opening 5.Next, a dilator 18 is inserted through sheath 22 to expand the innerdiameter thereof, as well as the inner diameters of the expandablemembers 14 a, 14 b and cannula 12, configured with dilator 18 in any ofthe manners described above, is slid into the sheath 22, followingdilator 18. Once cannula 12 has been inserted so that a distal endthereof is flush, or, more typically, extending slightly distally (e.g.,ranging from flush up to a distance of about 1 cm) from a distal endsurface of expanded expandable member 14 a, dilator 18 is removed,thereby completing the installation of port device 10, which is nowready to receive instruments or other devices therethrough to carry outone or more surgical procedures.

FIGS. 4A-4E illustrate another version of a port device 10 andprocedural steps included in its installation. Although shown beinginstalled in a left atrial appendage, device 10 can be installedanywhere on the heart 2 for access into the heart 2. Furtheralternatively, device 10 can be installed in any of the other internalorgans, vessels or other tissues described previously. In FIG. 4A,expandable member 14 a is stretched over a distal end portion of anintroducer needle 24 in a compact, non-expanded configuration, andexpandable member 14 b is stretched over a distal end portion of cannula12, and the distal end portion of needle 24, together with expandablemember 14 a are delivered through an opening 5 that can be formed usingany of the techniques described above with regard to FIGS. 3A-3C.Balloons 14 a, 14 b can be independently inflatable and the materialextending between these balloons is a single layer (which may be thesame or different material than that used to make the balloons) and thatneeds to be dilated after inflation of balloons 14 a, 14 b.

Expandable members 14 a, 14 b in this case are inflatable balloons,e.g., balloons formed of a thin laver of elastomer, such as silicone,latex, polyurethane etc. The material joining the two expandable membersthat is position through opening 5 can also be the same as the materialfor the expandable members, but is typically not inflated, only expandedby dilation. Device 10 also contains one or two lumens extending throughcannula 12 and one extending through to join expandable member 14 a, forinflating the expandable members 14 a. 14 b, wherein the one or twolumens are configured in the same manner as in the cannula 12 described,with regard to FIG. 1A above.

Once expandable member/distal end of cannula are abutting or in closeproximity to the outer surface of the tissue wall 1 of atrial appendage4 as illustrated in FIG. 4B, expandable member 14 a can be released fromneedle 24. Expandable member 14 a must be low profiled (cross-sectionaldimension) to follow the needle hole during insertion. The expandablemember be released from needle 24 after inflation of expandable member14 a by withdrawing the needle 24 proximally when expandable member 14 ais attached to needle via a perforated sleeve. Alternatively, this tearaway can occur from forces applied to it by expansion of the expandablemember 14 a alone. Further alternatively, release can be performed byrelease of a suture knot outside of the body to release tension on asuture holding balloon 14 a to needle 24. Upon expanding the expandablemember 14 a to secure the device against the inner surface of the tissuewall 1, this prevents device 10 from being pulled out as needle 24 isretracted, and needle 24 can be removed from the site, see FIG. 4C. InFIG. 4D, expandable member 14 b is expanded to, together with expandablemember 14 a, form an axially compressive seal of the opening 5, byatraumatically axially compressing against the inner and outer tissuewalls surrounding opening 5. At this stage, device 10 is installed andconfigured to accept other instruments, devices, etc, therethrough forperformance of one or more surgical procedures within the organ, vesselor other anatomical structure that device 10 provides access to.Installation of device 10, as well as the subsequent proceduresperformed through device 10 can all be performed in a minimally invasivemanner. FIG. 4E is a sectional illustration of the opening 5 as formedand hemostatically sealed by device 10 in a manner as described withregard to FIGS. 4A-4D above. The connecting material 14 c that connectsexpandable members 14 a and 14 b passes through opening 5 and isexpandable by dilation as additional tools or devices are passedtherethrough. Expandable member 14 a is also annular and includes acentral opening therethrough 14 ac that permits passage of theadditional tools and/or devices.

FIGS. 5A-5D illustrate another version of a port device 10 andprocedural steps included in its installation. Although shown beinginstalled in a let atrial appendage 4, device 10 can be installedanywhere on the heart 2 for access into the heart 2. Furtheralternatively, device 10 can be installed in any of the other internalorgans, vessels or other tissues described previously. In thisembodiment expandable members 14 a, 14 b are formed of an elastomeric,biocompatible foam, such as a closed-cell (e.g., nitrile rubber,silicone rubber, polyethylene, polyurethane, polyvinyl chloride, or thelike) foam wherein expandable members can be manipulated to assume afirst, contracted conformation in which expandable members 14 a, 14 beach have a relatively small outside diameter, and to assume a second,expanded conformation in which expandable members 14 a, 14 b, each havea relatively larger, expanded outside diameter.

One way of providing such expandable members is to mold the expandablemembers in a substantially hour-glass shape (similar to that shown inFIG. 5B, for example) with an annular opening running longitudinallythrough the center thereof to allow cannula 12 to be insertedtherethrough. In this configuration, the contracted conformation can beachieved by stretching the expandable members 14 a, 14 b axially over amandrel, such as an introducer needle 24, for example, as illustrated inFIG. 5A, and fixing the stretched foam material at a proximal endportion thereof and at a distal end portion thereof with releasable ties27. Upon releasing ties 27, the expandable members return to theirpremolded hourglass-like shape illustrated in FIG. 5B. FIG. 5Cillustrates wire or suture, or other tether material which is slidablyreceived through ends of releasable tie 27 to maintain compression oftie 27 against portion 14 a or 14 b and mandrel 24, to maintain thetension on the expandable members 14 a,14 b as shown in FIG. 5A anddescribed above. Upon releasing one end of wire/suture/tether 28 andsliding it out of the ends of releasable tie 27, the compressive forceis released, and the expandable member resumes its expandedconfiguration. Releasable tie may be fixed at one or more locations tothe expandable member so that it need not be removed.

Accordingly, the expandable member 14 a is inserted, together withintroducer needle distal end portion 24 through the opening formed bytip 24 and into the atrial appendage 4 in a manner as describedpreviously. Once in place, wires/sutures/tethers 28 are actuated torelease the compressive forces by the releasable ties that aremaintaining the expandable members 14 a,14 b stretched out in tensionover the introducer 24, whereby expandable members retract toward oneanother, and radially expand to assume the hourglass configuration shownin FIGS. 5B and 5D. Regardless of whether expandable members 14 a, 14 bare self-expanding, or are driven to expand, the expandable membersaxially compress the tissue in an atraumatic manner to hemostaticallyseal the opening 5. Once the expandable members 14 a and 14 b haveassumed the expanded configurations, the introducer 24 is removed, and adilator 18/cannula 12 combination can be inserted through the centralopening of the expandable members to install cannula 12 in a manner asalready described above, see FIG. 5D.

FIGS. 6A-6B illustrate another version of a port device 10 for any ofthe uses described previously herein. Thus, installed shown as installedin a left atrial appendage 4, device 10 can be installed any where onthe heart 2 for access into the heart 2. Further alternatively, device10 can be installed in any of the other internal organs, vessels orother tissues described previously. In this embodiment, expandablemembers 14 a if formed of a resilient, self expanding ring that can beelastically deformed to assume a much smaller diameter than the expandeddiameter illustrated in FIG. 6A. Thus, for installation of this device10 a small hole 5 is cut through the tissue wall 1 of the organ, vesselor other tissue into which device is to installed (in this example, theleft atrial appendage 4). The expandable member 14 a, in the compressedor elastically deformed conformation having a much smaller diameter thanin the expanded configuration, is inserted through the opening 5 and theallowed to expand in the cavity on the opposite side of the tissue wall1. For example, expandable member 14 a may be a ring of spring steel(stainless steel), an elastic polymer or a soft inelastic polymer, or asuperelastic material, such as nickel-titanium alloy (e.g., Nitinol), orother biocompatible material having similar structural and elasticproperties, that is solid and allows for inflation of the expandablemember. Optionally, at least a surface of expandable member 14 a thatfaces the tissue wall that it is to form a seal with, may be coated withsilicone or other biocompatible elastomer or other biocompatible softmaterial to assist in making the seal of the expandable member 14 a tothe tissue wall. In the compressed/elastically deformed conformation,elastic member 14 a can be delivered though opening 5 via a cannula 12,for example, or other structure designed to maintain the expandablemember 14 a in the compressed confirmation until being releasedtherefrom by the cannula or other compressive structure.

Once expandable member 14 a is allowed to expand, cloth (e.g., Dacron,woven polymer, or other known biocompatible fabrics acceptable forinternal use) or non-compliant, but flexible polymer arms 30 that areattached to expandable member 14 a and which extend out of opening 5 canbe tensioned/retracted, to pull expandable member 14 a against the innersurface of the tissue wall 1 thereby forming an atraumatic hemostaticseal. Flexible arms 30 may have an adhesive 32 coated on all or aportion of the side of each arm facing the external surface of thetissue wall 1, so that once expandable member 14 a has been retractedsufficiently to form a hemostatic seal against the inner surface oftissue wall 1, arms 30 can be pressed against the outer surface oftissue wall 1, thereby adhering the arms to the tissue wall 1 andmaintaining the hemostatic seal. Additionally or alternatively, arms 30may be sutured, stapled and/or tacked to the tissue wall.

FIG. 6B illustrates a thin film 34 that extends across expandable member14 a and forms a seal therewith. Film 34 may be a thin sheet ofsilicone, latex, or polyurethane, for example. A slit 34 s is providedin film 34 that functions like a one way valve. When installed asdescribed with regard to FIG. 6a above, film 34 prevents substantialamounts of blood or other fluids from flowing therethrough and out ofopening 5. However, when it is desired to insert a tool or device, thiscan be accomplished by passing the tool or device through the slit.After performing the intended function with the tool and the tool isremoved, or when the device no longer extends through the slit, the slitautomatically recluses, again preventing or substantially reducing fluidloss out of the opening 5.

FIG. 7A illustrates a closure device 40 that may be used to close anopening 5 through a tissue wall upon removal of port device 10therefrom. Device 40 is adapted for use with any of the devices 10described herein that employ cannula 12. For those devices 10 that donot employ cannula 12, device 40 can still be used to perform closureafter removal of such device 10 by providing a cannula with device 40for delivery thereof. FIGS. 7B-7D show steps that may be performed usingdevice 44) to close opening 5. For devices 10 employing cannula 12,these steps are performed after compacting at least expandable member 14a back to a reduced outside diameter, compact configuration. Forsimplicity, expandable members 14 a and 14 b are not shown in FIGS.7B-7D, as the same steps may be performed whether a device 10 havingexpandable member 14 a in a compact conformation is used, or a cannula12 having no expandable members is inserted after removal of a device 10that does not employ cannula 12.

Device 40 comprises a malleable wire having barbs 42 formed at both endsthereof. Device 40 has a central acute bend 44 and a pair of additionalacute bends 46 in an opposite direction. A locking ring 48 that isslidable over the wires of device 40 is initially positioned proximallyadjacent this additional pair of bends 46. A pusher rod or wire 50 isattached to the central acute bend 44 and has sufficient column strengthto push device 40 distally through cannula 12, and sufficient tensilestrength to pull barbs 42 though the tissue wall 1. Bends 44, 46 allowdevice 40 to be elastically deformed/compressed to be pushed thoughcannula 12. Once barbed ends 42 clear the distal end of cannula 12, suchas by pushing device 40 through cannula 12 by pushing on pusher rod/wire50 from a location proximal of the proximal end of cannula 12 andoutside of the patient's body, the barbed ends 42 spring radiallyoutwardly beyond the outside diameter of cannula 12, Pusher rod/wire 50can then be retracted proximally until bends 46 approach the distal endof cannula 12, as illustrated in FIG. 7B. Locking ring 48 remainspositioned just proximal of bends 46 and may be positioned adjacent thedistal end of cannula 12, as shown. In this position, locking ring helpsimprove the rigidity of the portions of device 40 that are external tocannula 12 to facilitate driving them through the tissue wall 1 asdescribed hereafter.

Barbs 42 can be driven through the tissue wall 1 solely by retractingpusher wire/rod 50 relative to cannula 12, or, alternatively, barbs canbe positioned adjacent the external surface of tissue wall 1 throughretracting pusher wire/rod 50, and then cannula 12 and pusher wire/rod50 can be retracted together to drive barbs 42 through the tissue wall1. In either case, after piercing through the tissue wall 1 with barbs42, cannula 12 and pusher rod/wire 50 are retracted further together. Ascannula 12 begins to exit the opening 5, the acute bends 46 begin todeform an increase in angle through right angle bends (FIG. 7C) toobtuse bend and then so that they are substantially straight or 180degree bends (FIG. 7D), as the barbs 42 maintain their relativepositions against the external surface of the tissue wall 1, since thebarbs prevent the ends of the device 40 from pulling back through thewall 1 during this retraction step. This causes the edges of the tissuewall 1 that define opening 5 to begin everting, as shown in FIG. 7C.Once bends 46 have substantially straightened, cannula 12 can beretracted relative to device 40, and locking ring 48 can be distallyadvanced and locked into position over detents 52. This further evertsthe tissue edges and closes the opening 5 and locks ring 48 intoposition to maintain the closure, as shown in FIG. 7D. Endoscopic cutteror scissors (not shown) can be inserted through cannula 12 to cut pusherrod/wire 50, thereby severing it from device 40 and cannula 12 andpusher rod/wire 50 can then be removed from the patient to complete theclosure and the procedure.

FIGS. 8A-8B illustrate another version of a port device 10 that can beused to provide an opening into an atrial appendage 4 for insertion oftools and/or devices therethrough to carry out a procedure inside achamber of the heart 2. Device 10 includes a pair of substantiallycylindrical rollers 60 each having at least one scallop or concavity 62formed therein and extending at least about 180 degreescircumferentially about the general cylindrical shape. Rollers 60 arepositioned substantially parallel to one another and joined by a linkage64 that permits the rollers to be separated from one another to increasea gap therebetween to allow the rollers to be placed over the atrialappendage 4 and then clamped on opposite sides thereof. Linkage 64 maybe spring-loaded, so that rollers can be separated, for example, usinggraspers, and then upon release of the rollers by the graspers,spring-loaded linkage 64 resiliently draws rollers back toward oneanother to a configuration such as shown in FIGS. 8A and 5B.

Spring force provided by linkage 64 may be a predetermined number ofpounds sufficient to clamp off the walls of the atrial appendage 4 toprevent blood flow therepast, but not so great as to cause tissue damageor necrosis (e.g., about one to about four pounds force, combined). Whenscallops 62 are aligned as shown in FIG. 5A, they join to define anopening where an opening 5 in the atrial appendage tissue wall 5 can beformed for access inside the atrial appendage 4. As rollers are rolledto the configuration shown in FIG. 8B, where only the cylindricalsurfaces abut the tissue wall, this effectively closes the opening 5,thereby substantially preventing fluid escape from the atrial appendage4.

Rollers 60 may be independently rotated (such as by using graspers orother endoscopic tool, for example) to align the scallops 62 for openingthe port, or to align the cylindrical surfaces to close the port.Alternatively, cylinders 60 may be linked, such as by gears 66 9 FIGS.8C and 5D) or other mechanical linkage so that rotation of only onecylinder 60 serves to rotate both, and thus providing easier alignmentof the scallops 62 or cylindrical surfaces, as the rotations are such asto guarantee equal rotations of both cylinders 60.

FIG. 9 illustrates a partial sectional view of another port device 10that, in addition to cannula 12 and expandable members 14 a, 14 b thatmay be configured in any of the manners described above, a seal 74(shown as a sectional view) is provided around cannula 12 at a locationproximal of the expandable member 14 b. Seal 70 includes a valve 72 suchas a duck-bill or trap door type valve that closes off the chamber 74defined around the opening when cannula 12 or cannula and expandablemembers 14 a, 14 b) are removed. Seal 70 may be provided with one ormore vacuum channels 76 connectable to a source of vacuum external ofthe patient (via one or more vacuum lines) to forma vacuum seal with theouter surface of the tissue 1. Seal 70 may be engaged with the outersurface of the tissue wall 1, such as by applying vacuum in the mannerdescribed, to establish the chamber prior to inserting cannula andexpandable member 14 a through the tissue, and even prior to making theopening 5, so as to contain any blood loss that may occur as opening 5is made and cannula 12 and expandable member 14 a are initially insertedthrough the opening 5. Expandable member 14 b may alternatively bereplaced by a flange that is not expandable, but has the shape shown inFIG. 9.

FIG. 10 illustrates a port device 10 comprising a cannula 12 having aclosable distal end portion 80. For example, distal end portion 80 maybe bullet shaped and include a pair of pivotally mounted, spring-biasedclamshell doors 82 that are spring loaded toward the closed position. Anelastomeric seal 84 may optionally be provided on one or both clamshelldoors 82 along the edges that abut one another during closing to furtherenhance the hemostatic seal. This bullet shaped distal end portion canbe inserted through an opening 5 in tissue wall 1 to form an atraumatic,hemostatic seal that allows insertion of instruments and/or devices.Upon insertion of an instrument, tool or device from a proximal endthrough cannula 12, contact of the tool, instrument or device againstthe internal surfaces of the clamshell doors 82 drives them open, asillustrated in phantom lines in FIG. 10. The bullet tip is elliptical inshape so that when clamshell doors 82 are open, the open edges of theclamshell doors are contoured to match or nearly match the shaft(typically cylindrical) of the instrument being inserted therethrough.This helps prevent fluid escaping therepast when the instrument isinserted through the open clamshell doors 82. Upon withdrawal of thetool or instrument, or when device no longer traverses the space betweenthe clamshell doors 82, the clamshell doors automatically close, drivenby the spring biasing, thereby re-establishing the hemostatic seal.

FIG. 11 illustrates another version of a port device 10 for any of theuses described previously herein. Thus, device 10 may be installedthrough the wall of a left atrial appendage 4, a right atrial appendage,or through any wall of the heart 2 for access into the heart 2. Furtheralternatively, device 10 can be installed in any of the other internalorgans, vessels or other tissues described previously. In thisembodiment, the main body portion of device 10 includes a plug 85 thatmay be formed of a polymeric foam, for example. Plug 85 includes acentral annulus 86 extending therethrough along a longitudinal axis ofthe plug 85. A channel 87 is formed circumferentially in and around anexternal portion of the plug 85 to receive the tissue edges around theopening formed through the tissue wall 1. Compression members 89 areconfigured to axially compress the plug 85 to expand the channelradially outwardly into contact with the tissue wall edges, therebysealing the opening. In one embodiment, compression members compriseelongate members 91 fixed to a distal portion of plug 85 and extendinglongitudinally through wall of the plug 85, wherein the walls areslidable with respect to the elongate members to allow compression withrespect thereto. Proximal portions of elongate member 91 includeratcheted teeth that cooperate with pads 93 which can be advanced tolock down against the plug, like a zip-tie function. Pads 93 can bedistally advanced over elongate member 91 and against plug 85 until plugcompresses sufficiently to expand channel 87 sufficiently radially toseal off the opening. The elongate members may also be flexible, so thatportions passing through the channel 87 tend to move radially outwardlyas tension is generated in the elongate members 89.

FIG. 12 illustrates another version of a port device 10 for any of theuses described previously herein. Thus, device 10 may be installedthrough the wall of a left atrial appendage 4, aright atrial appendage,or through any wall of the heart 2 for access into the heart 2. Furtheralternatively, device 10 can be installed in any of the other internalorgans, vessels or other tissues described previously. In thisembodiment, cannula 12 is provided as a hollow screw and thus has athreaded distal end portion 88 that can be used to screw cannula 12 intoand through the tissue wall 1. An expandable member 14 b may be providedto inflate and axially compress the tissue wall against the counterforceof the threads to atraumatically, hemostatically seal the opening 5.

FIG. 13 illustrates another version of a port device 10 for any of theuses described previously herein. Thus, device 10 may be installedthrough the wall of a left atrial appendage 4, a right atrial appendage,or through any wall of the heart 2 for access into the heart 2. Furtheralternatively, device 10 can be installed in any of the other internalorgans, vessels or other tissues described previously. In thisembodiment, a trocar 90 having a heatable, sharp distal tip portion 90 tis inserted through cannula 12 during the formation of opening 5 andinstallation of cannula 12 therein. Trocar 90 includes a power cord 92extending from a proximal end thereof that is electrically connectableto a power source 94 to provide energy to the distal tip portion 90 tthereby heating it through resistive heating, for example. The heated,sharp tip 90 t pierces easily though the tissue wall 1 by means ofmelting the tissue with an optional lesser degree of mechanicalpiercing. The distal end portion of cannula 12 can be coated withcollagen or other biocompatible material that fuses or otherwise sticksto the tissue in the opening 5 when the tissue is heated by tip 90 tpassing therethrough. This thus forms a hemostatic seal between thetissue defining the opening 5 and the outer wall of cannula 12.

As noted earlier, with the minimally invasive installation of any of theport devices 10 described herein, instruments, tools and/or devices canthen be inserted through the port device 10 for the performance of oneor more minimally invasive surgical procedures. FIG. 14A illustrates adistal end portion of an assembly 100 that can be inserted through portdevice 10 to visualize structures in the internal chamber accessedthrough the port device 14 as well as to perform ablation procedureswhile directly visualizing the tissues to be ablated and with theability to directly visualize the tissues as they are being ablated andafter ablation. For example, when a port is installed through a tissuewall of the left atrial appendage 4, assembly 100, having an endoscope200 mounted therein, can be inserted through port device 10 and used asan instrument to visualize structures on the wall of the left atrium andin the chamber of the left atrium. Ablation around the pulmonary veinscan be performed. Linear ablation lesions can be performed similarly, aswill be described further below.

A halo assembly 102 is installed over shaft 122 (which may be the shaftof an endoscope or a cannula into which an endoscope shaft is inserted).Halo assembly includes an expandable halo 104 formed of electricallyconducting superelastic wires, that are capable of being elasticallydeformed as they are drawn down (by retracting pushrods 106) to thecompact configuration shown in FIG. 14A, but which elastically expand toan expanded configuration when they are pushed distally with respect tothe shaft 122. An endoscope shaft may be inserted through shaft 122.Monopolar or bipolar electrocautery current may be delivered to thewires of halo 104 to ablate tissue surfaces contacted by the wires. Halo104 may be formed of two wires, in a substantially oval shape, as shownin FIG. 14A or with four wires, in a more circular or diamond shape whenexpanded. A pin 100 p or other electrical connector is provided forconnection to an external power source to supply current to the wires ofhalo 104. One or more of pushrods 106 electrically connect the pin orother electrical connector 100 p with the wires of halo 104. A coupler110 f couples the assembly 102 to the endoscope 200 in the example shownin FIG. 14D. Stainless steel crimps 108 connect the pushrods 106 to halo104 and help to keep the profile of halo 104 reduced when retracted,while allowing expansion of halo 104 over balloon 124 when balloon 124is expanded. Pushrods 106 retract to different retracted locations alongcannula 122 so that one end of halo 104 is located more proximally thanan opposite end as this facilitates reducing the overall diameter of theretracted halo 104. In the deployed configuration however, push rod 106move the locations where they are connected to halo 104 all tosubstantially the same axial location relative to cannula 122, whichfacilitates expanding halo 104. Balloon 124 is in fluid communicationwith a source of pressurized fluid (e.g., saline) which can be inputtedto greatly expand the size of the balloon to provide a viewing spaceinto which the distal tip of the endoscope is inserted for viewing in aninternal chamber of an organ, tissue or other structure having aninternal chamber. Balloon 124 is typically made of an elastomer, such assilicone or latex, for example, and may be formed as what is sometimesreferred to in the art as a balloon tip trocar (BTT). In at least oneembodiment the wires of halo are made form Nitinol wire of about 0.012″diameter pre-shaped to form an encircling configuration when not underelastic compression. Superelastic wires having a diameter in a range ofabout 12 mm to about 25 mm are typically useable.

Pushrods 106 are connected proximally to an actuator 110 that isslidable over shaft 122 to either retract halo 104 when actuator isretracted proximally along shaft 122, or to extend and expand halo 104when actuator is pushed distally with respect to shaft 122. In FIG. 14A,halos 104 is shown retracted, with actuator 110 in the retractedposition relative to shaft 122, and balloon 124 is in a non-inflatedstate.

When balloon 124 is inflated and pressed up against a structure in aninternal cavity, this substantially displaces blood or other fluid thatmay have been surrounding that structure and enables viewing of thestructure via the distal tip of the endoscope residing in the inflatedballoon.

FIG. 14B shows the distal end portion of assembly 100 where balloon 124has been inflated/expanded, e.g. with saline and halo 104 is thenextended over balloon 104 and positioned against a distal surface ofballoon 124. Balloon 124 may be inflated by infusion through the inletof conduit 124 c (FIG. 14D) that provides fluid communication between aproximal end portion of the instrument and the balloon 124. For example,for a balloon that is provided over the end of a cannula 122 having anoutside diameter of about 5 mm to about 7 mm, balloon 124 can beexpanded up to at least about 30 mn in diameter, thus allowing arelatively large area of anatomy to be viewed at once. Because of theexpansion of the superelastic wires in halo 104 and the compliance ofballoon 124, halo 104 can be slid over the balloon 124 in the expandedconfiguration shown. Alternatively, halo 104 can be expanded first andthen balloon 124 can be inflated to result in the same configurationshown in FIG. 14B. However, balloon 124 is typically inflated first, asthe inflated balloon is used to first inspect the surgical site andlocate a target area to be ablated. Then halo 104 is deployed overballoon 124 to the configuration shown in FIG. 148 and the halo can thenbe accurately positioned on the location to be ablated, since thesurgeon can now view the target tissue as well as the halo 104 throughballoon 124 and the endoscope.

FIGS. 14A and 14B show an example of a halo apparatus in which halo 104is formed from two wires. FIG. 14C shows a distal end view of FIG. 14C,showing the substantially oval shape formed by halo 104 in the expandedconfiguration against the distal surface of balloon 124.

As noted, shaft 122 may be provided as a cannula into which the shaft ofan endoscope 200 can be inserted to provide a viewing and ablationinstrument. FIG. 14D shows balloon in a non-inflated, non-expanded ordeflated configuration with halo 104 deployed in the extended andexpanded configuration. Endoscope 20 (5 mm Scholly Model 259008 0°/WA,in the embodiment shown) is inserted into shaft (cannula) 122 to placethe distal tip of endoscope 200 within balloon 124. Endoscope 200 may beconnected to cannula 122 by threading at proximal portions thereof, orby bayonet connector, or other mechanical connector.

Pushrods 106 interconnect halo 104 and actuator 110 which is slidableover shaft 122. An extension 110 e of actuator 110 is provided to allowmanipulating from a location proximal of the assembly 100, typically inthe vicinity of the proximal end portion of endoscope 200. In at leastone embodiment, the wires forming halo 104 have a diameter of about0.014″ and are formed of Nitinol (nickel-titanium alloy) and pushrods106 are stainless steel and have a diameter of about 0.037″. Crimps 108may be coated with white heat shrink tubing 108 s and pushrods 106 maybe coated with heat shrink tubing 106 s (clear, in the example of FIG.14D) which, in one particular embodiment increases the overall diameterof pushrods 106 from about 0.037″ to about 0.047″ in other embodiments,pushrods having smaller outside diameters are used.

FIGS. 15A-15B illustrate a halo assembly wherein halo 14 is formed fromfour superelastic wires. FIG. 15B is an illustration of a distal endview of halo 104 showing the substantially diamond-shaped orquadrilateral configuration of halo 104 and connection points 104 cwhere pushrods 106 connect via crimps 108. FIG. 15C shows a portion ofassembly 100 having a four-wire halo 104 and in which actuator 110 hasbeen incorporated into a halo cover 110 c. In one specific embodiment,halo cover has an outside diameter of about 0.375″.

FIG. 15D illustrates assembly 100 having a four wire halo 104 with halo104 shown in the deployed position and expanded configuration, whileballoon 124 is deflated, in a non-expanded configuration. FIG. 15E showsthe assembly of FIG. 15D with halo 104 in a retracted position andcompressed configuration, and wherein balloon 124 has beeninflated/expanded FIG. 15F shows the halo 104 beginning to be deployedover the expanded/inflated balloon 124 by manipulating actuator 110,110e, such as by pushing on the actuator extension 110 e to drive actuator110, pushrods 106 and halo 104 distally relative to balloon 124, andwherein halo 104 begins to expand as it is distally driven FIG. 15Gshows halo 104 fully deployed over the inflated balloon 124 so that itresides against the distal surface of the inflated balloon 124. FIG. 15Hshows the substantially expanded configuration of halo 104 at the distalsurface of balloon 124, in a distal end view of the balloon 124 and halo104 in the configuration shown in FIG. 150. It can be observed that thehalo configuration is much closer to a circular configuration that thatshown in FIG. 15B and is substantially square.

FIG. 16 illustrates a distal end portion of an assembly 300 configuredto form a linear lesion while directly viewing the tissue in which thelesion is being formed. Similar to assembly 100, assembly 300 includes acannula 122 having an inflatable balloon mounted over the distal endthereof. Cannula 122 is configured and dimensioned to receive the shaftof endoscope 200 so that the distal tip of endoscope 200 can bepositioned at the opening or within balloon 124 for visualizationthrough the balloon. FIG. 16 shows balloon in an inflated (expanded)configuration. A conduit 306 extends through cannula 122 and is in fluidcommunication with balloon 124 and configured to be connected in fluidcommunication with an inflation source (e.g., pressurized saline, orother suitable fluid) proximal of the assembly 300. An electricalconnector (e.g., wire) 304 extends from ablation element 302 out of theproximal end portion of cannula 122 to be connected to a power sourcefor supplying power to the ablation element 302 to perform ablation. Forexample, ablation element 302 may be a monopolar or dipolar conductiveelement that cauterizes contacted tissue when power is supplied thereto.Alternatively, other types of ablation energy may be used, such as, butnot limited to: radio frequency (RF) energy, microwave energy,cryogenic, laser, etc. or chemical substance. Connector 304 may extendparallel to conduit 20 or through conduit 306, for example.

Ablation element comprises a metallic tip 302 mounted to a distalsurface of balloon 124, preferably centrally mounted on the distalsurface, although other locations may be chosen for mounting on thedistal surface. Upon insertion of endoscope 200 into assembly 30) andthen insertion of this instrument through a minimally invasive opening(such as provided via installation of one of the port devices 10described herein, for example), balloon 124 can then be inflated, asshown, and then the instrument can be manipulated to slide the distalsurface of the inflated balloon 124 along anatomical structures in thespace into which the instrument was inserted. For example, in the casewhere the instrument is inserted through the left atrial appendage, andone or more encircling lesions have been performed around pulmonary veinostia (such as by using a device of the types described in FIGS. 14A-15Hfor example), the inflated balloon 124 and endoscope 200 can bemanipulated to visualize the pulmonary ostia, the encircling lesion(s)and the mitral annulus. Once the surgeon has familiarizedhimself/herself with these locations, a linear lesion can be ablated toconnect the encircling lesion(s) with the mitral annulus, by applyingenergy to ablation element 302 and dragging the ablation element fromthe encircling lesion(s) to the mitral annulus or vice versa, whileviewing the ablation procedure, including the element 302 applyingenergy to the target tissue, through balloon 124 and endoscope 200.

A similar procedure can be performed using an instrument comprising anendoscope 200 inserted into an assembly 100 to form one or moreencircling lesions around the pulmonary veins. In this procedure,identification and viewing of the location of the pulmonary veins can beconducted with balloon 124 inflated and halo 104 still in the retractedposition and configuration. Once the surgeon has familiarizedhimself/herself with these locations, one or more encircling lesions canbe ablated around the pulmonary veins by first deploying the halo to thedeployed and expanded configuration on the distal surface of theexpanded balloon 124, positioning the balloon against the target tissueso that the halo (as visualized through the balloon 124 and endoscope2000 encircles the pulmonary ostia to be ablated around, and applyingenergy to halo 14 to create an encircling lesion, while viewing theablation procedure, including the halo 104 applying energy to the targettissue, through balloon 124 and endoscope 200. It is further noted, thatduring sliding movements of the expanded balloon 124 against the tissuesurface, balloon 124 can tend to deform somewhat due to the forces ofthe friction between the balloon and the tissue during sliding movementsand the compliant nature of the balloon material. When halo 104 isdeployed over the balloon 124 as described above, the structure of thehalo 104 helps to rigidify the balloon structure somewhat during thesemovements, thereby reducing the amount of balloon lag and time that ittakes for the balloon to become axially aligned with the cannula 122after a sliding movement.

FIG. 17 illustrates an assembly 400 that combines the linear ablationcapabilities of assembly 300 with the encircling lesion formingcapabilities of halo 104 in assembly 100. In this case, ablation element302 and halo 104 are independently connectable to one or external energysources and are independently controllable, so that ablation energy canbe applied though element 302 without applying ablation energy to halo104, and vice versa. Accordingly, using an instrument formed byinserting an endoscope 200 into assembly 400, one or more encirclinglesions can be formed around the pulmonary veins in a manner asdescribed above. Then, by either retracting halo 104 or leaving it inthe deployed configuration, expanded balloon 124 can be manipulated tolocate and visualize the target location for forming a linear ablationlesion, such as to connect the encircling lesion(s) with the mitralannulus, for example, and energy can be applied through ablation element302 while dragging it and visualizing the lesion formation in a manneras described above. Since the balloon 124 is filled with saline, thisacts to protect the balloon material from damage by the ablation element302 and/or halo 104 as ablation energies are delivered therethrough toablate the target tissues that the halo 104 or ablation element 302 andballoon 124 are contacted against during the ablation.

FIG. 18 illustrates steps that may be carried out during a minimallyinvasive procedure using one or more of the devices and/or instrumentsdescribed herein. At step 602, after prepping a patient for surgery, aminimally invasive opening is made in the patient, through the skin, ina location determined to best provide access to the organ, vessel ortissue in which a surgical procedure is to be conducted. Examples ofsuch an opening include, but are not limited to, a thoracotomy, amini-thoracotomy, establishment of a percutaneous port to the thoracicor abdominal cavity, or a percutaneous puncture at any location throughthe skin providing an access route to the target site.

At step 604, a hemostatically sealed port is established through thewall of an organ, vessel or tissue having an inner, fluid containingchamber (referred to as the target tissue), inside which a surgicalprocedure is to be conducted Examples of target tissues (organ, vesselor other tissue) in which a hemostatically sealed port device may beinstalled through a wall thereof were described above. In oneembodiment, a port device is installed through the wall of a left atrialappendage. In another embodiment, a port device 10 is installed though awall of the heart at or near the apex of the heart to provide access tothe left ventricle chamber. The hemostatically sealed is port isinstalled/established solely by minimally invasive techniques, wherein aport device 10 and any tools used to install the port device 10 areadvanced to the target tissue through a minimally invasive opening inthe patient. Many of the port devices 10 described herein have a cannulahaving sufficient length to extend out of the opening through the skinof the patient (and thus outside of the patient) even when thehemostatic seal is made to establish the port through the target organ,vessel or other tissue. Once the hemostatic port 10 has beensuccessfully installed, at least one tool, instrument and or device arepassed through the port and into the internal chamber to conduct atleast one step of a surgical procedure, see step 606. Many differentsurgical procedures are possible, including those practiced by currentendoscopic methods. In one example, atrial ablation is performed in anyof the manners described above. In another example, heart valve surgeryis conducted, and/or a heart valve prosthesis having already beenimplanted is directly visually inspected. After completion of the atleast one surgical procedure step, the port is cleared of all tools,instrument and devices and the opening through the wall of the targettissue is closed, step 608. After this, closure of the patient iscompleted, including closing the opening through the skin, step 610.

FIG. 19 illustrates an endoscopic trocar assembly 500 configured toreceive an endoscope 200 therein for use as an instrument to visualizepiercing through a tissue wall 1 and gaining access to an interiorchamber located inside the tissue wall 1. In one particular embodimentthe instrument comprising the trocar assembly 500 with endoscope 200inserted therein, as illustrated in FIG. 19, is used to gain entry intothe left ventricle by piercing the tissue wall of the heart near theapex. It is noted that this instrument is not limited to this use, butcan be used in similar manner to gain access and visualize the processof gaining access as the sharp distal tip of the instrument piercesthrough the tissue wall 1 of any of the organs, vessels, or tissuesdescribed above.

The endoscopic trocar assembly 500 includes a rigid trocar sleeve 502typically having an outside diameter of about 5 mm to about 10 mm and inwhich a hemostatic valve 504 is provided in the annular space thereof,at a proximal end portion thereof. Optionally, the distal portion may beprovided with expandable members 14 a and 14 b, shown in phantom linesin FIGS. 19 and 20A, in the expanded configurations in both views. Theobturator inside the trocar 502 is formed by endoscope 2 having adistal, transparent tip covering the distal end 202 of the endoscope200. Distal tip 506 is sharp at the distal end thereof and may form apointed tip. For example, distal tip 506 may be conically tapering downto a sharp point 506 p. The proximal end of trocar 502 functions as astop when contacted by stop member 204 on endoscope 200 when endoscope200 has been fully inserted into trocar 502. Tip 506 has an outsidediameter smaller than the inside diameter of trocar 502 so that it isreadily slidable through the trocar, and the majority of tip 506 extendsdistally of the distal end 502 d of trocar 502 when endoscope 2 is fullyinserted into trocar 502. Likewise, the distal end 202 of endoscope 200extends distally of the distal end 502 d of trocar 502 in thisconfiguration. The sharp, transparent distal tip 506 is attached to thedistal end 202 of endoscope 200 such as by mating threads 506 t, 202 t,or other mechanical connection members, in any case, forming a fluidtight seal against the endoscope 200.

FIG. 20A illustrates use of the instrument comprising the endoscopictrocar assembly 500 and endoscope 20 to advance through the myocardiumof the heart 2 at a location near the apex 6 of the heart to access theleft ventricle 7. Following the creation of an opening through the skinof the patient (e.g., such as in a manner described with regard to step602 above, for example) and a pathway to the vicinity of the apex 6 ofthe heart 2, the instrument is delivered through the minimally invasiveopening, aligned with a location near the apex 6 and driven into themyocardium to pierce the myocardial tissue wall with sharp tip 506.Visualization of the piercing of tip 506 through the myocardial wall canbe accomplished through endoscope 200 and clear tip 506. Uponvisualization of blood via this visualization technique, this isconfirmation that the myocardium has been pierced through and theendoscopic obturator (i.e., endoscope 20 and tip 506) is removed fromtrocar 502, leaving trocar 502 in place through the myocardial wall andinto the ventricle 7, as illustrated in FIG. 20B. In the optionalembodiment, where expandable members 14 a and 14 b are employed, theseexpandable members are provided in a compressed, compact configurationclose to the trocar 502 as the trocar is inserted. Expandable member 14a may then be expanded/inflated and the trocar 502 can be retracted topull expanded expandable member 14 a into contact with the internalmyocardial wall of the left ventricle near the apex. Expandable member14 b can then be expanded/inflated to form a hemostatic seal of theentry into the ventricle, together with expanded, expandable member 14a, as illustrated in FIG. 20A. Endoscope 200 may be withdrawn formtrocar 502 either before or after expansion of the expandable members.Whether or not expandable members 14 a,14 b are used, instruments, toolsand/or devices may then be introduced through trocar 502, withhemostatic valve 504 forming a hemostatic seal, substantially preventingoutflow of blood/fluids from the ventricle. Instruments that can beinserted and used include, but are not limited to endoscopic ballooncannulae each having an operating channel through which surgicalprocedures can be performed on the endocardial surface and on thecardiac valves.

Following performance of an endocardial procedure, a seal 508 isintroduced to close the tract formed by the endoscopic trocar 502. FIG.21A illustrates seal 508. Seal 508 may be constructed of a sheet ofprosthetic graft material e.g., woven polyester or Dacron, and isattached to a suture 510 that may be nylon or polypropylene, forexample. Suture 510 runs through the lumen of an inner tube 512 that isrigid and may have an outside diameter of about 1 mm to about 2 mm, forexample. Inner tube 512 extends through an outer sleeve 514 having anouter diameter sized to form a slip fit inside endoscopic trocar cannula502. The length of outer sleeve 514 is slightly longer than trocar 502so that the distal end 514 d extends slightly distally of the distal end502 d of trocar 502, when sleeve 514 is fully inserted into trocar 502as illustrated in FIG. 20C. Sleeve 514 includes a stop 514 s that abutsagainst the proximal end of trocar 502 when sleeve 514 has been fullyinserted into trocar 502.

The length of inner tube 512 is selected so that when inner tube 512 isfully inserted into outer sleeve 514 (i.e., when stop 512 s abuts stop514 as shown in FIGS. 21C and 20E), the distal end 512 d extendsdistally from distal end 514 d by a distance that is greater than thethickness of the myocardium. Typically, this length should be selectedso that seal 508 extends a distance 516 of about 6 cm distally of distalend 514 d when inner tube 512 is fully inserted in sleeve 514 and seal508 extends distally from, but contacts distal end 512 d. A hemostaticvalve or seal 518 in the proximal end portion of outer sleeve 514 allowsinner tube 512 to slide with respect thereto while maintaining a fluidtight seal, and a hemostatic valve or seal 520 in the proximal endportion of inner tube 514 allows suture 510 to slide relative to innertube 512 while maintaining a fluid tight seal (see FIG. 21B).

The inner tube 512 and suture 510 can be retracted relative to sleeve514 to pull the seal into sleeve 514, as illustrated in FIG. 21B. Inuse, the sealing assembly is inserted into trocar 502 with the seal (ormembrane seal) 508 in the retracted position, as shown in FIG. 20C. Theinner tube 512 is next distally advanced by a predetermined distance(which can be indicated by an optionally placed mark on the outside ofthe inner tube 512 at a proximal portion thereof extending proximallyfrom sleeve 514 to push seal 508 out of outer sleeve 514 and into theventricle, as illustrated in FIG. 20D.

While holding inner tube 512 stationary relative to the heart 2, trocar502 and outer sleeve 514 are next retracted proximally back to aposition where stop 514 s abuts stop 512 s as shown in FIG. 20E, leavingonly inner tube 512 inside the tract 9 vacated by trocar sleeve 502.This permits the tract 9 to shrink down to the size (inside diameter)about equal to the outside diameter of inner tube 512, thereby ensuringthat seal 8 stays inside the ventricle 7 and is not pulled out throughthe trocar sleeve 502 or through a large diameter tract through themyocardium. After allowing the tract 9 to shrink down around inner tube512, inner tube 512 is pulled out of tract 9 and out of the body (trocar502 and sleeve 514 are also removed from the body, either at the sametime as removal of inner tube 512 or just prior thereto), leaving seal 8inside the ventricle 7 tethered to suture 510 which extends out of thebody. A vascular clip 520 is placed on the outside wall of the ventricle7 opposite seal 508 which is drawn against the inside surface of thewall of the ventricle 7 as shown in FIG. 20F. Vascular clip may beadvanced over suture 510 using an endoscopic clip applier advancedthrough the working channel 602 of an endoscopic visualization cannula600 (e.g., FlexView from Boston Scientific Cardiac Surgery, Santa Clara,Calif.). Alternatively, a sliding suture loop 622 inside a knot pushertube 620 (similar to an Endoloop from Tyco Autosuture Corp., or thelike) may be placed through the working channel 602 of endoscopicvisualization channel 600, advanced over suture 510, cinched down on theoutside wall of the ventricle 7 opposite seal 508, which is drawnagainst the insider surface of the wall of ventricle 7, see FIG. 20G.The tails of suture 510 and sliding suture loop 622 can be cut off withendoscopic shears under visualization through use of endoscopicvisualization cannula 600. Vascular clip 520 or cinched suture loop 622thus maintains seal 508 compressed against the inner surface of theMyocardial wall, thereby covering the tract 9, with seal 508 anchored inplace to provide hemostasis to the ventricular tract 9.

Alternative to the use of a sheet of prosthetic graft material to formseal 508, seal 508 may be provided as a collagen plug that is installedto close and seal the tract formed by the endoscopic trocar 502. Theseembodiments of seal 508 can be placed in the same manner as describedabove with regard to placement of the seal made from a sheet ofprosthetic graft material. However, rather than forming a seal over theinside wall surface of the wall in which the opening has been formed andwhich is being sealed off, these embodiments of seal are pulled at leastpartially into the opening (in a direction from the inside wall surfacetoward the outside wall surface) to wedge within the wall (myocardialwall or other wall having been pierced) in order to seal the opening. Inthe case of a trans-apical procedure on the heart, this provides postprocedure hemostasis.

The collagen material from which seal 508 is made in these embodimentsinduced fibrotic growth into seal 508 and seal 508 also bio-absorbs overtime, leaving a permanent tissue seal. FIG. 22A illustrates a conical orwedge-shaped seal 508 comprising collagen, as connected by suture 510which passes through inner tube 512. For simplicity of illustration,outer sleeve 514 has not been shown in FIG. 22A, but would be usedduring installation of seal 508, as noted. FIG. 22B illustrates aspherical or ball-shaped seal 508 comprising collagen, as connected bysuture 510 which passes through inner tube 512. For simplicity ofillustration, outer sleeve 514 has not been shown in FIG. 22B, but wouldbe used during installation of seal 508, as noted.

FIG. 23A illustrates a conical or wedge-shaped seal 508 having beenwedged into the opening in the myocardial wall to seal the opening.Alternatively, the seal 508 may be bullet-shaped and inserted in thesame way. FIG. 23B illustrates a spherical or ball-shaped seal 508inserted into the tract in the myocardial wall to seal the same. Inthese embodiments, suture or tether 510 may be made of a bioabsorbablematerial, so that the suture 510 bio-absorbs as well as the seal 508,thereby leaving a completely natural seal. These embodiments may beanchored in any of the same ways described above with the regard to theseals 508 made from a sheet of graft material. In the examples shown inFIGS. 23A and 23B, clip 521 has been anchored to suture 510 against theexternal surface of the myocardium, to prevent seal 508 from migratingout of the tract and into the let ventricle.

The present invention includes a port device for establishing ahemostatically sealed port through an opening in a tissue wall whereinan inside surface of the tissue wall interfaces with a fluid containingchamber, the device including: a cannula configured to be insertedthrough the opening in the tissue wall; and a first feature configuredto impart an axial force on the tissue wall in a direction away from thefluid containing chamber, wherein axial force on the tissue wall forms ahemostatic seal substantially preventing fluid from escaping through theopening between said cannula and the opening.

In at least one embodiment, a second feature is configured to impart anaxial force on the tissue wall in a direction opposing the axial forceimparted by the first feature, wherein the tissue wall is axiallycompressed to form the hemostatic seal.

In at least one embodiment, the first feature comprises an expandablemember configured to assume a collapsed configuration with a relativelysmaller diameter, and an expanded configuration with a relatively largerdiameter, wherein the expandable member expands radially away from thecannula upon expanding.

In at least one embodiment, the first feature comprises a firstexpandable member configured to assume a collapsed configuration with arelatively smaller diameter, and an expanded configuration with arelatively larger diameter, wherein the expandable member expandsradially away from the cannula upon expanding, and wherein the secondfeature comprises a second expandable member configured to assume acollapsed configuration with a relatively smaller diameter, and anexpanded configuration with a relatively larger diameter, wherein thesecond expandable member expands radially away from the cannula uponexpanding; and wherein the first expandable member is located around adistal end portion of the cannula and the second expandable member islocated proximally adjacent the first expandable member such thatexpansion of the first and second expandable members when positioned onopposite sides of the tissue wall axially compresses the tissue wall.

In at least one embodiment, the first and second expandable memberscomprise first and second balloons.

In at least one embodiment the cannula is rigid.

In at least one embodiment, the first and second balloons areinterconnected by a thin, flexible tubular sheath, and the cannula isinsertable though central openings formed in the first and secondballoons and through the tubular sheath.

In at least one embodiment, the first and second features compriseelastomeric foam, wherein the first and second features are extendablealong the cannula in a first configuration having a relatively smallerdiameter and wherein the first and second features are configurable to asecond, expanded configuration wherein each of the first and secondfeatures assume a relatively larger diameter, wherein the first andsecond features expand radially away from the cannula.

In at least one embodiment, at least one actuator is provided foraxially compressing the first and second features to move from the firstconfiguration to the second, expanded configuration.

In at least one embodiment, the first feature is located around a distalend portion of the cannula and the second feature is located proximallyadjacent the first feature such that expansion of the first and secondfeatures when positioned on opposite sides of the tissue wall axiallycompresses the tissue wall.

In at least one embodiment, a closure assembly, configured to close theopening after removal of the cannula, is provided.

In at least one embodiment, the closure assembly comprises adouble-ended wire having barbs at both ends and configured to bedelivered through the cannula, the barbs being drivable though thetissue wall in a direction from the inside surface to the outsidesurface.

In at least one embodiment, a locking ring is slidable into detentsprovided on the wire of the closure assembly to maintain the barbs in aconfiguration holding tissue edges around the opening in a closed,everted orientation.

In at least one embodiment, a pusher element is attachable to the wireand has a length greater than a length of the cannula, and the pusherelement is sufficiently rigid to push the wire through the cannula.

In at least one embodiment, a seal member extending over the cannula andsurrounds the first feature.

In at least one embodiment, the first feature comprises screw threadingon a distal end portion of the cannula, and the second feature comprisesan expandable member configured to assume a collapsed configuration witha relatively smaller diameter, and an expanded configuration with arelatively larger diameter, wherein the second expandable member expandsradially away from the cannula upon expanding.

An assembly for establishing a hemostatically sealed port through anopening in a tissue wall is provided, wherein an inside surface of thetissue wall interfaces with a fluid containing chamber, and the assemblycomprises: a port device including a cannula having a biocompatiblematerial on a distal end portion thereof that fuses or adheres to thetissue wall at the perimeter of the opening when heated, and a trocarhaving a sharp distal tip heatable to a temperature to at leastpartially melt tissue of the tissue wall as it is advanced therethrough,wherein the trocar is slidable through the cannula.

An assembly for establishing a hemostatically sealed port through anopening in a tissue wall is provided, wherein an inside surface of thetissue wall interfaces with a fluid containing chamber, and the assemblycomprises: a port device including a cannula configured to be insertedthrough the opening in the tissue wall and a first feature configured toimpart an axial force on the tissue wall in a direction away from thefluid containing chamber, wherein axial force on the tissue wall forms ahemostatic seal substantially preventing fluid from escaping through theopening between the cannula and the opening; and a dilator insertablethrough the cannula and having a sharp distal tip, wherein the sharp tipof the dilator is adapted to form the opening through the tissue andwherein the dilator dilates the opening formed by the sharp tip and thecannula is advanced through the dilated opening together with thedilator.

In at least one embodiment, the dilator is removably attachable withinthe cannula.

In at least one embodiment, the port device further comprises a secondfeature configured to impart an axial force on the tissue wall in adirection opposing the axial force imparted by the first feature,wherein the tissue wall is axially compressed to form the hemostaticseal.

In at least one embodiment, the first feature comprises a firstexpandable member configured to assume a collapsed configuration with arelatively smaller diameter, and an expanded configuration with arelatively larger diameter, wherein the expandable member expandsradially away from the cannula upon expanding; wherein the secondfeature comprises a second expandable member configured to assume acollapsed configuration with a relatively smaller diameter, and anexpanded configuration with a relatively larger diameter, wherein thesecond expandable member expands radially away from the cannula uponexpanding; and wherein the first expandable member is located around adistal end portion of the cannula and the second expandable member islocated proximally adjacent the first expandable member such thatexpansion of the first and second expandable members when positioned onopposite sides of the tissue wall axially compresses the tissue wall.

In at least one embodiment, the first and second expandable memberscomprise first and second balloons.

An assembly for establishing a hemostatically sealed port through anopening in a tissue wall is provided, wherein an inside surface of thetissue wall interfaces with a fluid containing chamber, and the assemblycomprises: a port device including first and second annularly shapedballoons interconnected by a thin, flexible tubular sheath; and aninserter having a sharp distal up for creating the opening through thetissue wall; wherein the first and second balloons and the tubularsheath are wrappable around the introducer to provide a first compactconfiguration having a reduced cross-sectional area, and wherein, uponcreating the opening with the distal tip and inserting a distal endportion of the introducer and the first balloon through the tissue wall,the first and second balloons are inflatable to expand to a second,expanded configuration that unwraps the first and second balloons andthe sheath, and wherein the first and second balloons axially compressthe tissue wall.

In at least one embodiment, a cannula is insertable through the secondballoon, the tubular sheath and the first balloon in the second,expanded configuration.

In at least one embodiment the cannula is rigid.

An assembly for establishing a hemostatically sealed port through anopening in a tissue wall is provided, wherein an inside surface of thetissue wall interfaces with a fluid containing chamber, and the assemblycomprises: a port device including a first expandable portion and asecond expandable portion; a rigid cannula; and an introducer having asharp distal tip for creating the opening through the tissue wall;wherein the first expandable portion is placed in a compactconfiguration over a distal end portion of the introducer and the secondexpandable portion is placed in a compact configuration over a distalend portion of the cannula; and wherein, upon creating the opening withthe distal tip and inserting the distal end portion of the introducerand the first expandable portion through the tissue wall, the first andsecond expandable portions are expanded to a second, radially expandedconfiguration wherein the first and second expandable portions axiallycompress the tissue wall.

In at least one embodiment, the introducer is removed after theexpansion of the expandable portions, leaving the port device forming ahemostatically sealed port through the tissue wall.

A port device for establishing a hemostatically sealed port through anopening in a tissue wall is provided, wherein an inside surface of thetissue wall interfaces with a fluid containing chamber, and the devicecomprises: a first feature configured to impart an axial force on thetissue wall in a direction away from the fluid containing chamber; and asecond feature configured to impart an axial force on the tissue wall ina direction opposing the axial force imparted by the first feature,wherein the tissue wall is axially compressed to form the hemostaticseal.

In at least one embodiment, the first feature comprises a resilient,self-expanding ring.

In at least one embodiment, the ring comprises a superelastic material.

In at least one embodiment, the second feature comprises a plurality offlexible arms attached to the first feature and adapted to extendthrough the opening.

In at least one embodiment, the flexible arms each comprise anattachment feature adapted to attach the flexible arms, respectively toan outer surface of the tissue wall.

In at least one embodiment, the attachment features comprise adhesive.

In at least one embodiment, a thin film extends across the ring andforms a seal therewith.

In at least one embodiment, the film comprises a slit therethrough.

A closure device for closing an opening in a tissue wall is provided,wherein an inside surface of the tissue wall interfaces with a fluidcontaining chamber, and the device is deliverable through a cannula andclosure is performed as a minimally invasive procedure. The deviceincludes a double-ended wire having barbs at both ends and configured tobe delivered through the cannula, the barbs being drivable though thetissue wall in a direction from the inside surface to the outsidesurface; and a locking ring slidable into detents provided on the wireto maintain the barbs in a configuration holding tissue edges around theopening in a closed, everted orientation.

In at least one embodiment, a pusher element is attachable to the wireand has a length greater than a length of the cannula and the pusherelement is sufficiently rigid to push the wire through the cannula.

A port device for establishing a hemostatically sealed port through anopening in a tissue wall is provided, wherein an inside surface of thetissue wall interfaces with a fluid containing chamber, and the devicecomprises: first and second rollers extending substantially parallel toone another and mechanically linked to allow separation thereof toincrease a space therebetween and movement together to reduce the space;and at least one scallop provided in each roller, wherein the rollersare rotatable to align the scallops to form an opening aligned with theopening in the tissue wall, and wherein the rollers are furtherrotatable to align cylindrical surfaces thereof with each other to closethe opening in the tissue wall and form a hemostatic seal.

In at least one embodiment, the rollers are resiliently biased towardone another.

A port device for establishing a hemostatically sealed port through anopening in a tissue wall is provided, wherein an inside surface of thetissue wall interfaces with a fluid containing chamber, and the devicecomprises: a cannula having a closable distal end portion, the distalend portion comprising a plurality of spring-biased clamshell doorsopenable to allow an instrument to be passed therethrough, the clamshelldoors being spring-biased to a closed configuration.

In at least one embodiment, the distal end portion is bullet-shaped whenthe clamshell doors are in the closed configuration.

A port device for establishing a hemostatically sealed port through anopening in a tissue wall is provided, wherein an inside surface of thetissue wall interfaces with a fluid containing chamber, and the devicecomprises, a plug having a central annulus extending therethrough alonga longitudinal axis of the plug; a channel formed circumferentially inand around an external portion of the plug and compression membersconfigured to compress the plug to expand the channel into contact withwall edges of an opening through a tissue wall.

An assembly usable in performing minimally-invasive ablation proceduresis provided that includes: an elongated shaft, a balloon fitted over adistal end of the elongated shall, the balloon being configured toassumed a deflated configuration, as well as an inflated configurationwherein the balloon has an outside diameter greater than an outsidediameter of the balloon in the deflated configuration; and a halocomprising wires configured to be positioned proximal of the balloon ina retracted configuration and movable to a position distal of theballoon in an expanded configuration, wherein, when in the expandedconfiguration, the halo defines an area larger than a contracted areadefined by the halo when in the retracted configuration.

In at least one embodiment, the halo is advanceable over the balloonwhen the balloon is in the inflated configuration.

In at least one embodiment, the halo comprises superelastic wires thatexpand a configuration of the halo when moving from the retractedconfiguration to the expanded configuration.

In at least one embodiment, the superelastic wires slide over theballoon and the balloon deforms somewhat as the halo passes from theretracted configuration to deploy over the balloon to the expandedconfiguration.

In at least one embodiment, a plurality of push rods are connected tothe halo, the push rods being axially slidable relative to the shaft tomove the halo from the retracted configuration position and thedeployed, expanded configuration position and vice versa.

In at least one embodiment, an actuator is connected to proximal ends ofthe push rods, the actuator being slidable over the shaft.

In at least one embodiment the actuator comprises an extension extendingproximally to a proximal end portion of the shaft.

In at least one embodiment, the halo is electrically connectable to asource of ablation energy proximal of the assembly.

In at least one embodiment, the halo is connectable to a source ofablation energy proximal of the assembly.

In at least one embodiment, a conduit connecting with the balloonextends proximally of a proximal end of the shaft, the conduit beingconnectable in fluid communication with a source of pressurized fluid.

In at least one embodiment, the shaft comprises a cannula, the cannulabeing configured and dimensioned to receive an endoscope shaft therein,with a distal tip of the endoscope being positionable within theballoon.

In at least one embodiment, the shaft comprises a shaft of an endoscope.

In at least one embodiment, the halo is formed of two wires and forms asubstantially oval shape when in the expanded configuration.

In at least one embodiment, the halo forms an encircling shape when inthe expanded configuration.

In at least one embodiment, the halo is formed of four wires and forms asubstantially quadrilateral shape when in the expanded configuration.

An instrument usable in performing minimally-invasive ablationprocedures is provided that includes: an elongated shaft; a balloonfitted over a distal end of the elongated shaft, the balloon beingconfigured to assume a deflated configuration, as well as an inflatedconfiguration wherein the balloon has an outside diameter greater thanan outside diameter of the balloon in the deflated configuration; and ahalo comprising wires configured to be positioned proximal of theballoon in a retracted configuration and movable to a position distal ofthe balloon in an expanded configuration, wherein, when in the expandedconfiguration, the halo defines an area larger than a contracted areadefined by the halo when in the retracted configuration; and anendoscope having a distal tip thereof positioned adjacent to an openingof the balloon or within the balloon.

In at least one embodiment, the shaft comprises a shaft of theendoscope.

In at least one embodiment, the shaft comprises a cannula and wherein ashaft of the endoscope is received in the cannula.

In at least one embodiment, the halo is advanceable over the balloonwhen the balloon is in the inflated configuration.

In at least one embodiment, the halo comprises superelastic wires thatexpand a configuration of the halo when moving from the retractedconfiguration to the expanded configuration.

In at least one embodiment, the superelastic wires slide over theballoon and the balloon deforms somewhat as the halo passes from theretracted configuration to deploy over the balloon to the expandedconfiguration.

In at least one embodiment, a plurality of push rods are connected tothe halo, the push rods being axially slidable relative to the shaft tomove the halo from the retracted configuration position and thedeployed, expanded configuration position and vice versa.

In at least one embodiment, an actuator is connected to proximal ends ofthe push rods, the actuator being slidable over the shaft.

In at least one embodiment, the actuator comprises an extensionextending proximally to a proximal end portion of the endoscope.

In at least one embodiment, the halo is electrically connectable to asource of ablation energy proximal of the instrument.

In at least one embodiment, the halo is connectable to a source ofablation energy proximal of the instrument.

In at least one embodiment, a conduit connecting with the balloonextends proximally of a proximal end portion of the shaft, the conduitbeing connectable in fluid communication with a source of pressurizedfluid.

In at least one embodiment, the halo is formed of two wires and forms asubstantially oval shape when in the expanded configuration.

In at least one embodiment, the halo forms an encircling shape when inthe expanded configuration.

In at least one embodiment, the halo is formed of four wires and forms asubstantially quadrilateral shape when in the expanded configuration.

An instrument facilitating the making of an opening, by endoscopictechniques, through a tissue wall is provided, wherein an inside surfaceof the tissue wall interfaces with a fluid containing chamber, whiledirectly visualizing the making of the opening, the instrumentcomprising: a rigid trocar sleeve; and an endoscope slidable within thetrocar sleeve and fitted with a transparent, sharp tip over a distal endof the endoscope, wherein the transparent, sharp tip is also slidablewithin the trocar.

In at least one embodiment, a stop is provided on a shaft of theendoscope, wherein, when the endoscope is inserted into the trocarsleeve to an extent where the stop abuts a proximal end of the trocarsleeve, the distal end of the endoscope and the transparent sharp tipare positioned distally adjacent a distal end of the trocar sleeve.

A sealing assembly for closing an opening, by endoscopic techniques,through a tissue wall is provided, wherein an inside surface of thetissue wall interfaces with a fluid containing chamber, and the assemblycomprises: a seal an inner tube, a suture attached to the seal andextending through the inner tube, the suture have sufficient length toextend proximally of the inner tube when the seal is positioned distallyof a distal end of the inner tube; and an outer sleeve configured toallow the inner tube to be advanced therethrough.

In at least one embodiment, the inner tube is rigid.

In at least one embodiment, the seal comprises woven polyester orDacron.

In at least one embodiment, the seal has a surface area larger than anarea of the opening to be closed.

In at least one embodiment, the suture comprises at least one of nylonand polypropylene.

In at least one embodiment, a trocar sleeve is provided, wherein theouter sleeve has an outside diameter sized to form a slip fit inside thetrocar sleeve.

In at least one embodiment, the outer sleeve has a length greater than alength of the trocar sleeve.

In at least one embodiment the trocar sleeve is rigid.

In at least one embodiment, the inner tube has a length greater than alength of the outer sleeve.

In at least one embodiment, the inner tube comprises a stop on aproximal end portion thereof, wherein when the inner tube is insertedinto the outer sleeve to an extent where the stop abuts a proximal endof the outer sleeve, a distal end of the inner tube extends distally ofa distal end of the outer sleeve by a predetermined distance that isgreater than a thickness of the tissue wall.

In at least one embodiment, the predetermined distance is about 6 cm.

In at least one embodiment, the suture and the inner tube areretractable, relative to the outer sleeve, to draw the seal into adistal end portion of the outer sleeve.

In at least one embodiment, the seal is deformed when it is drawn intothe distal end portion of the outer sleeve.

A method of establishing a hemostatically sealed port through an openingin a tissue wall is provided, wherein an inside surface of the tissuewall interfaces with a fluid containing chamber, the method includingthe steps of: providing a minimally invasive opening through the skin ofa patient; advancing a sharp instrument, through the minimally invasiveopening to the tissue wall; establishing an opening through the tissuewall, by manipulating the instrument from outside of the patient; andinstalling a port device though the opening in the tissue wall andforming a hemostatic seal between the port device and the opening, bymanipulations performed by an operator outside of the patient.

In at least one embodiment, the installing comprises inserting a distalend portion of the port device including a distal end portion of acannula and a first expandable member through the opening through thetissue wall to position the first expandable member inside of an insidesurface of the tissue wall, and expanding the first expandable member.

In at least one embodiment, a second expandable member is expanded at alocation outside of an outside surface of the tissue wall, wherein thefirst and second expandable members axially compress the tissue wall.

In at least one embodiment, the first expandable member is an inflatableballoon.

In at least one embodiment, the first expandable member comprisespolymer foam.

In at least one embodiment, the first expandable member comprises anexpandable stent.

In at least one embodiment, the second expandable member is aninflatable balloon.

In at least one embodiment, the second expandable member comprisespolymer foam.

In at least one embodiment, the second expandable member comprises anexpandable stent.

In at least one embodiment, at least one surgical procedure is performedthrough the tissue wall by inserting at least one tool, instrument ordevice through the port device and manipulating the at least one tool,instrument or device from a location outside of the patient.

In at least one embodiment, the tissue wall is a tissue wall of anatrial appendage.

In at least one embodiment, the atrial appendage is the left atrialappendage.

In at least one embodiment, the tissue wall is a myocardial wall of theheart of the patient.

In at least one embodiment, the opening is made in the myocardial wallat or near the apex of the heart, providing access to the leftventricle.

In at least one embodiment, a proximal end portion of the cannulaextends out of the patient, through the minimally invasive openingthrough the skin, after the step of installing the device to form thehemostatic seal.

In at least one embodiment, the step of establishing an opening throughthe tissue wall comprises piercing the tissue wall and dilating thetissue wall with a dilator, and wherein a portion of the port device,following the dilator is inserted through the opening through the tissuewall, after which the dilator is removed.

In at least one embodiment, the step of establishing an opening throughthe tissue wall comprises piercing the tissue wall with a sharp tip ofan inserter, and wherein first and second expandable members arecompressed and wrapped around the inserter, wherein the installing theport device comprises inserting the first expandable member through theopening through the tissue wall, expanding the first expandable memberinside of the tissue wall, expanding the second expandable memberoutside of the tissue wall, and withdrawing the inserter.

In at least one embodiment, a rigid cannula is inserted through annularopenings in the first and second expanded expandable members.

In at least one embodiment, the step of establishing an opening throughthe tissue wall comprises piercing the tissue wall with a sharp tip ofan inserter, and wherein a first expandable members is placed, in anon-expanded configuration over a distal end portion of the inserter,and a second expandable member is placed, in a non-expandedconfiguration over a distal end of a cannula, and wherein the installingthe port device comprises inserting the distal end portion of theinserter and first expandable member through the opening through thetissue wall, expanding the first expandable member inside of the tissuewall, expanding the second expandable member outside of the tissue wall,and withdrawing the inserter.

In at least one embodiment, the step of establishing an opening throughthe tissue wall comprises piercing the tissue wall with a sharp tip ofan inserter, and wherein an expandable member is placed, in anon-expanded configuration over a distal end portion of the inserter,and wherein the installing the port device comprises inserting thedistal end portion of the inserter and a first expandable portion of theexpandable member through the opening through the tissue wall, expandingthe first expandable portion inside of the tissue wall, expanding asecond expandable portion of the expandable member outside of the tissuewall, and withdrawing the inserter.

In at least one embodiment, a rigid cannula is inserted through annularopenings in the first and second expanded expandable portions.

In at least one embodiment, the step of installing comprises inserting aresilient ring portion of the port device, while in a reduced sizeconfiguration through the opening through the tissue wall; allowing theresilient ring to expand to an expanded configuration; drawing the ringagainst an inner surface of the tissue wall, and fixing a plurality ofarms attached to the ring and extending through the opening in thetissue wall to an outer surface of the tissue wall.

In at least one embodiment, the step of installing comprises placing apair of rollers on the tissue wall, against an outer surface thereof onopposite sides of the opening through the tissue wall; and compressing adouble thickness of the tissue wall together by relative movement of therollers toward one another.

In at least one embodiment, the rollers are rotated to align scallopsprovided in both rollers, thereby allowing access through the openingvia an opening between the rollers provided by the scallops.

In at least one embodiment, the step of installing comprises placing apair of rollers on the tissue wall, against an outer surface thereof onopposite sides of a target location where the opening through the tissuewall is to be formed, compressing a double thickness of the tissue walltogether by relative movement of the rollers toward one another rotatingthe rollers to align scallops provided in both rollers, thereby allowingaccess to the tissue wall by the sharp instrument to form the openingthrough the tissue wall.

In at least one embodiment, a sealing member is sealed on an outersurface of the tissue wall, to establish a sealed working space prior toat least one of the establishing an opening through the tissue wall andthe installing a port device though the opening.

In at least one embodiment, the step of installing comprises inserting aclosable, bullet-shaped distal end of a cannula through the openingthrough the tissue wall, wherein the bullet-shaped distal end ispushable open by inserting a tool, instrument or device through thecannula, and is spring biased to automatically close when no tool,instrument or device is positioned between portions of the openabledistal end, thereby hemostatically sealing the distal end.

In at least one embodiment, an ablation procedure is performed on anendocardial surface of the left atrium.

In at least one embodiment, at least one instrument is inserted into theleft ventricle.

A method of performing ablation by minimally invasive methods whiledirectly visualizing the ablation procedure is provided, including thesteps of advancing an instrument through a minimally invasive openingthrough the skin of a patient and through an opening through a tissuewall to enter a fluid containing chamber against an inner surface ofwhich ablation is to be performed; expanding a balloon at a distal endof the instrument; contacting the expanded balloon against an innersurface of a wall of the chamber, visualizing the inner surface of thewall of the chamber in a location contacted; identifying a targetlocation to ablate by the contacting and visualizing steps, whileintermittently moving the balloon to contact different locations, ifnecessary until the target location is identified; advancing a halo overthe balloon to position the halo around an identified location andagainst the target location to be ablated, between the target locationand a distal surface of the balloon; and applying ablation energy thoughthe halo while visualizing the halo and target location through theballoon.

In at least one embodiment, the chamber is the left atrium, theidentified location is at least one pulmonary vein ostium, and thetarget location is an inside surface of the atrial wall surrounding theat least one pulmonary vein ostium.

In at least one embodiment, the step of applying ablation energy formsan encircling lesion in the tissue at the target location.

In at least one embodiment, the opening through the tissue wall includesa port device installed therethrough forming a hemostatic seal betweenthe port device and the opening, and wherein the instrument is insertedthrough the port device.

In at least one embodiment, the instrument is removed from the patient,and the method further includes: advancing a second instrument throughthe minimally invasive opening through the skin of the patient andthrough the opening through the tissue wall to enter the chamber;expanding a balloon at a distal end of the second instrument; contactingthe expanded balloon against an inner surface of a wall of the chamberto locate a lesion formed by the applying ablation energy; visualizingthe lesion through the balloon contacting the lesion; aligning anablation element on a distal surface of the balloon to contact thelesion; applying ablation energy though the ablation element, whiledragging the ablation element along tissue to form a linear lesion; andvisualizing movement of the ablation element and formation of the linearlesion as the ablation element is dragged and ablation energy isapplied.

A method of performing ablation by minimally invasive methods whiledirectly visualizing the ablation procedure is provided, including thesteps of advancing an instrument through a minimally invasive openingthrough the skin of a patient and through an opening through a tissuewall to enter a fluid containing chamber against an inner surface ofwhich ablation is to be performed; expanding a balloon at a distal endof the instrument; contacting the expanded balloon against an innersurface of a wall of the chamber; visualizing the inner surface of thewall of the chamber in a location contacted; identifying a targetlocation to ablate by the contacting and visualizing steps, whileintermittently moving the balloon to contact different locations, ifnecessary until the target location is identified, aligning an ablationelement on a distal surface of the balloon to contact the targetlocation; applying ablation energy though the ablation element, whiledragging the ablation element along tissue to form a linear lesion; andvisualizing movement of the ablation element and formation of the linearlesion as the ablation element is dragged and ablation energy isapplied.

A method of establishing, by endoscopic techniques, an opening through atissue wall wherein an inside surface of the tissue wall interfaces witha fluid containing chamber, while visualizing the establishment of theopening, is provided, including the steps of: providing a minimallyinvasive opening through the skin of a patient, advancing an instrumentincluding an endoscope having a sharp, transparent tip mounted on adistal end thereof, and a trocar, wherein the endoscope is slidablyreceived in the trocar and the tip extends distally from a distal end ofthe trocar, through the minimally invasive opening to the tissue wall,and driving the sharp, transparent tip through the tissue wall whilevisualizing the passage of the sharp, distal tip into the tissue walland through the wall, where the fluid is visualized, visualization beingperformed through the endoscope.

In at least one embodiment, the endoscope and sharp tip are withdrawnfrom the patient, leaving the trocar installed through the tissue wallto function as a port.

In at least one embodiment, a proximal end portion of the trocar extendsout of the patient, through the minimally invasive opening through theskin when a distal end portion of the trocar is inserted through thetissue wall.

In at least one embodiment, at least one surgical procedural step iscarried out that includes advancing at least one of a tool, instrumentor device through the trocar and into the fluid containing chamber.

In at least one embodiment, the tissue wall is a myocardial wall of theheart.

In at least one embodiment, the tip is driven though the tissue wall ata location at or near the apex of the heart, and the chamber is the leftventricle.

In at least one embodiment, trocar is removed, the method furtherincluding hemostatically closing a tract left by insertion of the trocarthrough the opening through the tissue wall.

In at least one embodiment, the closing comprises, introducing a sealthrough the tract and into the chamber; retracting the seal against thetract opening and an inner surface of the tissue wall surrounding thetract opening, by retracting a suture attached to the seal and extendingthrough the tract, through the opening through the skin and out of thepatient; and advancing a clip over the suture and against an outersurface of the tissue wall to maintain tension on the suture, therebymaintaining the seal compressed against the inner surface.

In at least one embodiment, the closing comprises: introducing a sealthrough the tract and into the chamber; retracting the seal against thetract opening and an inner surface of the tissue wall surrounding thetract opening, by retracting a suture attached to the seal and extendingthrough the tract, through the opening through the skin and out of thepatient; and advancing a suture loop over the suture and against anouter surface of the tissue wall, and cinching the suture loop againstthe outer surface of the tissue wall to maintain tension on the suture,thereby maintaining the seal compressed against the inner surface.

A method of hemostatically closing is provided, by minimally invasiveprocedures, a tract formed by insertion of a trocar through a tissuewall wherein an inside surface of the tissue wall interfaces with afluid containing chamber, the method including the steps of: inserting aseal through the trocar and into the chamber, the trocar having beeninserted through a minimally invasive opening through the skin of apatient and through an opening in the tissue wall; retracting the trocarto remove it from the opening through the tissue wall; retracting theseal against the tract opening and an inner surface of the tissue wallsurrounding the tract opening, by retracting a suture attached to theseal and extending through the tract, through the opening through theskin and out of the patient; and advancing a clip or suture loop overthe suture and securing the clip or suture loop against an outer surfaceof the tissue wall to maintain tension on the suture, therebymaintaining the seal compressed against the inner surface.

Further provided is a method of hemostatically closing, by minimallyinvasive procedures, an opening where a cannula is placed through atissue wall wherein an inside surface of the tissue wall interfaces witha fluid containing chamber, the method including the steps of:delivering a closure assembly through the cannula and into the chamber;retracting the closure assembly to drive barbs of the closure assemblythrough the tissue wall in a direction from the inside surface to theoutside surface; partially withdrawing the cannula to begin evertingtissue edges defining the opening; completely withdrawing the cannulaand sliding a locking ring on the closure assembly into a lockedposition to maintain the tissue edges everted and hemostatically sealingthe opening.

While the present invention has been described with reference to thespecific embodiments thereof, it should be understood by those skilledin the art that various changes may be made and equivalents may besubstituted without departing from the true spirit and scope of theinvention. In addition, many modifications may be made to adapt aparticular situation, material, composition of matter, process, processstep or steps, to the objective, spirit and scope of the presentinvention. All such modifications are intended to be within the scope ofthe claims appended hereto.

1-29. (canceled)
 30. A hemostatic port device, comprising: a cannula; aneedle located within the cannula, wherein a distal end portion of theneedle is distal to a distal end portion of the cannula; a firstexpandable member mounted over the distal end portion of the cannula;and a second expandable member mounted over the distal end portion ofthe needle so there is a gap located between the first expandable memberand the second expandable member, wherein the second expandable memberand the first expandable member are annular, and wherein when the firstexpandable member and the second expandable member are expanded, thefirst expandable member and the second expandable member expand tocapture tissue therebetween so as to form a hemostatic seal with thetissue.
 31. The hemostatic port device of claim 30, further comprising:a pressurized fluid source disposed to deliver pressurized fluid to eachof the first expandable member and the second expandable member so as toinflate the first expandable member and the second expandable member.32. The hemostatic port device of claim 30, wherein the first expandablemember is an inflatable balloon stretched over the distal end portion ofthe cannula, and the second expandable member is an inflatable balloonstretched over the distal end portion of the needle.